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Gaulin, Paul it gg-- NEW YORK STATE DEPARTMENT OF HEALTH r" I. Vital Records Section Burial - Transit Permit Name First Middle Last Sex Paul Donald Gaulin Male Date of Death Age If Veteran of U.S. Armed Forces, July 14, 2018 75 War or Dates Vietnam Place of Death Hospital, Institution or 1 City, Town or Village Hudson Falls Street Address 11 William Street CI Manner of Death Natural Cause E Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending III Circumstances Investigation L Medical Certifier Name Title Charles Yun, Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Hudson Falls 6-7�6 /5 0 Burial Date Cemetery or Crematory July 18, 2018 Pine View Crematory {❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address AMP Hold 0 Date Point of ❑Transportation Shipment 0 by Common Destination 0 Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped, If Other than Above I; Address I i . Permission is hereby granted to dispose of the human remains cribed above as indicated. Date Issued 7 j7,26 i g Registrar of Vital Statistics S Q_ ,-%, (signature) District Number ,5-7a26 Place y_clQ0.a„z ,.,,t k- L I certify that the remains of the decedent identified ab e were disposed of in accordance with this permit on: 1 Date of Disposition 07/18/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) iii a (section) /' (lot number) (grave number) 0 Name of Sexton or Person in Charge of Pr mises [ �� cr St^��t 6ase print) ILI Signature Title f m910 (over) DOH-1555 (02/2004)