Lillibridge, Gary N. JJL3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gary N Lillibridge Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/24/2020 68 Years War or Dates 1971-74
F— Place of Death Hospital,Institution or
Z City,Town or Village Corinth Town Street Address 410 County 24 Route,Corinth Town, New York 12822
p Manner of Death Natural Cause XI AccidentHomicide Suicide Undetermined Pending
Circumstances Investigation
LU Medical Certifier Name Title
0 Eugene Ladue Coroner
Address
31 Woodlawn Ave.,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Corinth 4553 29
0 Burial Date Cemetery,Crematory or Facility Name
10/28/2020 Pineview Crematory
0 Entombment Address
ElCremation Queensbury Town,New York
0 Donation
Z ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
t1. Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
2 Address
Q
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/27/2020 Registrar of Vital Statistics Brenda L Peris(Electronically Signed)
(signature)
District Number 4553 Place Corinth, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �1
Z Date of Disposition /12 fig to Place of Disposition ?_I(/t.& £f�--
2 (address)
W
N CC (section) (lot number) (grave number/
IA n CIS
at
Name of Sexton or Person in Cha f Premises i.� „05w
(p_ se prin /
LU Signature Title c ro�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) J 11196
Receipt
Human remains of delivered on , 20
Pine View Cemetery R-epresentingliefuneral home named on burial permit
Official Funeral Directors Reg.or License#