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Gifford, Kevin Dean 88i6 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records - Name First Middle Last Sex Kevin Dean Gifford Male Date of Death Age If Veteran of U.S.Armed Forces, 10/20/2021 53 Years War or Dates F.. Place of Death Hospital,Institution or WCity,Town or Village Thurman Town Street Address 799 Stoney Creek Road,Thurman Town, New York 12810 ▪ Manner of Death ❑ Natural Cause ❑Accident Homicide ©Suicide ❑Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Athol 5659 011 Burial Date Cemetery,Crematory or Facility Name 10/25/2021 Pine View Crematory ❑Entombment Address lCremation Queensbury,New York Donation o• ElRemoval Date Place Removed and/or and/or Held p N Hold Address IL =1 Date Point of (/) Li Transportation B by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom �.. Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/25/2021 Registrar of Vital Statistics Susan Staples(Electronically Signed) (signature) District Number 5659 Place Athol, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z iW Date of Disposition /O'Z(�IL1 Place of Disposition (address) W (section) 11(lot number) (grave number) Name of Sexton or Person in Charge of Premises n,%Af` �`""`'�11 11, (pleas print/WSignature Title (Ftermis;ye DOH-1555(07/18)p 1 of 2 #asuaon JO.2aN sioloa.ua'mound Mol..140 Monad Fl.mq uo'Daum autoq piaunj alp upuasalciali XJalatuaD main°um I oz uo ponAllop Jo suremat uutunH lcIpooN t F (qz)stit .3°S 1Wel trU01-1 °Wind r