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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records ,,'_
Name First Middle Last Sex
Gatlin M Willard Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/14/2022 30 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Troy Street Address 19 South River Road,Troy,New York 12180
0 Manner of Death Undetermined Pending
W EilNatural Cause Accident1=1 Homicide Suicide g
Circumstances Investigation
W Medical Certifier Name Title
0 Dennis Chute MD
Address
168 Washington St,Poughkeepsie,New York 12601
Death Certificate Filed City Of Troy District Number Register Number
City,Town or Village 4102 553
HBurial Date Cemetery,Crematory or Facility Name
10/22/2022 Pineview Crematory
Entombment Address
['Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
I Hold Address
N
0
d. Date Point of
(I)['Transportation
El by Common Shipment
Carrier Destination
O
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
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W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/18/2022 Registrar of Vital Statistics Heather L Mulinio(Electronically Signed)
(signature)
District Number 4102 Place City Of Troy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Z Date of Disposition /D~ZZ-Zo7 Place of Disposition P`,n/P (f t e,A) Cr elyt n4-v h.(
2 (address)
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N
Cr
(section/ (lot numr) (grave number)
0 Name of Sexton or Person in Charg f Premises A�m I'") i"�'aD
—Z (please print)
IJJ Signature —_ e 1/ Title o6_eTTv
DOH-1555(07/18)p 1 of 2
9
634
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#