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Hathaway Sr, Gary Paul _ 11- SLI NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records i6 • Name First Middle Last Sex Gary Paul Hathaway Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 02/05/2021 60 Years War or Dates p.,. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death © Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title G Sean Bain MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 87 ❑Burial Date Cemetery,Crematory or Facility Name 02/08/2021 Pine View Crematory ❑Entombment Address 1771 OW Cremation Queensbury Town,New York EDonation Z Removal Date Place Removed Q and/or and/or Held Hold Address CO— O. Date Point of N ❑Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address C W 11. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/08/2021 Registrar of Vital Statistics Men Andrew Curtis(ECectronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: II— Z Date of Disposition 7 pi 1?I Place of Disposition e' ....'LZ11/, 2 (address) Ili NCC (section) t(lot numb (grave number) 0 Name of Sexton or Person in Charge of Premises (A . i1. tY Z / (p/ee print/ W Signature Title /00;,typy _e. DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014510 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#