Gorrie, David Allen - ni.\ -\''" 1®-z\
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
David Allen Gorrie Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/21/2022 57 Years War or Dates
l.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death nUndetermined Pending
El Natural Cause nAccident ElHomicide Suicide I I g
111
0 Circumstances Investigation
ILI Medical Certifier Name Title
0 Matthew Loftus PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 645
nBurial Date Cemetery,Crematory or Facility Name
12/22/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
- and/or and/or Held
~- Hold Address
N
0
CI. Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
lilDisinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
11J
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/22/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— , /
Z Date of Disposition /Z.-Z j-z,7 Place of Disposition ,,deV.e,,J C he'r J a, ;-...
2 (address)
W
CCCC (section) _ (lot number) (grave number)
0 Name of Sexton or Person in Charge remises 1l`n'�� w pD
(please print)
W �_� e-rw
Signature Title D�
DOH-1555(07/18)p 1 of 2
y - T �. c, .^. •^ ny tom,
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#