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Dupuis Sr., Gordon Manley NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gordon Manley Dupuis Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 05/02/2021 73 Years War or Dates 1968-1989 Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address 41 Haviland Avenue,Glens Falls,New York 12801 p Manner of Death © Natural Cause 0 Accident ❑Homicide El SuicideUndetermined �Pending Circumstances Investigation W Medical Certifier Name Title CI Joseph Mihindukulasuriya MD Address 20 Murray Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 199 ElBurial Date Cemetery,Crematory or Facility Name 05/05/2021 Pine View Crematorium 0 Entombment Address X❑Cremation Queensbury Town,New York ❑Donation c ❑Removal Date Place Removed and/or and/or Held F— Hold Address 0 d Date Point of N LI Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom i— Remains are Shipped,If Other than Above g Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/05/2021 Registrar of Vital Statistics cRpbertAndrew Curtis(E(ectronically 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: W F_s)Date of Disposition 5-4IZl Place of Disposition2 I , W CC CC (section) (lot number) (grave number) O Name of Sexton or Person in Charge Premises 11'-.1 ilk.- --Cm.v"�` Z ( ease print) /�}}�,�,, y���A W Signature Title r' '�'"►^ 1 UII DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) ' :1 ,1 Receipt Human remains of delivered on , 20'- Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#