Gibbs, Jr. William ff
NEW YORK STATE DEPARTMENT OF H TH r
Vital Records Section Burial - Transit Permit
84 Name First Middle Last Sex
P& William Frank •• Male
--irg Date of Death Age If Veteran of U.S. Armed Forces,
10- 03/14/2018 ./ Years War or Dates
Place of Death Hospital, Institution or
City Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Deathrm
aj Natural Cause Accident Homicide Suicide Ej Undetermined ri Pending
,1"'„ Circumstances "4 Investigation
*,%' Medical Certifier Name Title
Jennifer Stratton MD
14y: Address
11 Park St,Glens Falls,New York ;1
to Death Certificate Filed District Number Register Number
otti City, Town or Village Glens Falls 5601 138
OBurial Date Cemeteryor Crematory
WI" 03/19/2018 Pine View Crematory
ry4a Address
T
l Cremation Queensbury Town, New York
Date Place Removed
■ Removal • • •
and/or
Address
Ho •
Date Point of
. TransportationShipment
by Common Destination
Si Carrier
Date Cemetery Address
Li Disinterment
Reinterment
Date Cemetery Address
N Permit Issued to Registration Number
4 Name of Funeral Home Maynard D Baker Funeral Home 01130
',V Address
,t* Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/19/2018 Registrarof Vital Statistics Ro6ert . a/ Signed)
• District Number 5601 Place
Glens Falls, New York
4,, certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
"‘",": Date of Disposition 3)Zi hit Place of Disposition
(section) frnumber) r (grave number)
Name of Sexton or Person in Charge of Premises lit.y Or
a (plea e print)
Signature Title tfrEA1-
(over)
DOH-1555(02/2004)