Gifford, Daniel Elmer r =
NEW YORK STATE DEPARTMENT OF HEALTH IO # 41
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Daniel Elmer Gifford Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/16/2022 67 Years War or Dates
1 . Place of Death Hospital,Institution or
WCity,Town or Village Valatie Village Street Address Barnwell Nursing And Rehabilitation Center
p Manner of Death a Natural Cause Accident 0 Homicide ESuicide Undetermined Pending
W V Circumstances Investigation
a Medical Certifier Name Title
Kathleen Steiger NP
Address
3230 Church St,Valatie Village,New York 12184
Death Certificate Filed Village Of Valatie District Number Register Number
City,Town or Village 1023 36
FliBurial Date Cemetery,Crematory or Facility Name
06/21/2022 Pine View Crematory
— Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
p and/or and/or Held
N Hold Address
0
O. Date Point of
U)❑Transportation
13 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/21/2022 Registrar of Vital Statistics Barbara Ann Fischer(ECectronica1TySigned)
(signature/
District Number 1023 Place Village Of Valatie
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition (�2a_ZvzL 0 , A
Place of Disposition l, u :e1,v i (4_417
(address)
W
N
Q (section) 'e (lot number) (grave number)
gName of Sexton or Person in Cha of Premi s . AKine9 ✓� L)cx(
Z L ,(please print)
W Signature Title (��j�f�.T�'V
DOH-1555(07/18)p 1 of 2 v
k.y fpq y, t f1.)
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#