Loading...
Gipson Jr., James W 8�6 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James W Gipson Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 10/18/2021 69 Years War or Dates 1971-1977 Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital LIJ Ip Manner of Death ©Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation WMedical Certifier Name Title CI Asim Chaudry MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 455 ❑Burial Date Cemetery,Crematory or Facility Name 10/22/2021 Pine View Crematory ElEntombment Address ]Cremation Queensbury,New York ❑Donation cS ❑Removal Date Place Removed and/or and/or Held ( Hold Address 11 0 a Date Point of WL j Transportation by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address fL W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/19/2021 Registrar of Vital Statistics WobertAndrew Curtis(Electronically 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: Z uJ Date of Disposition /0-22 �- 2[ Place of Disposition r y e✓;e. .i Ue n,,6 Ayr-, (address) W (I) (section/ (lot number) (grave number) gName of Sexton or Per n in Charge of Premises W`t a►^ (9w..s 44.4 e (please print) /1 W Signature Title L"le-01- % 607�g" DOH-1555(07/18) of 2 i ....__ . ,. 015242 # Public Health Law Sec. 4145(2b) • Receipt 9 iHuman remains of ' ` delivered on - -_. , 20 d 1 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#