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Jordon, Gary M. Sr. . . ., ' ,,, NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records r Name First Middle Last Sex Gary M Jordan Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 09/25/2023 81 Years War or Dates 1961-1964 H Place of Death Hospital,Institution or Z City,Town or Village Long Lake Town Street Address 156 Burketown Avenue Lot 36,Long Lake Town,New York 13436 LLI p Manner of Death ❑^ Natural Cause Accident 111 Homicide ESuicide nUndetermined El Pending Ill 0 Circumstances Investigation W Medical Certifier Name Title CI Matthew Miller Coroner Address P.O. Box 250, Indian Lake,New York 12842 Death Certificate Filed Town Of Long Lake District Number Register Number City,Town or Village 2056 7 EBurial Date Cemetery,Crematory or Facility Name 09/29/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,Warren,New York ▪Donation OZ❑Removal Date Place Removed and/or and/or Held F- Hold Address N 0 a. Date Point of M Transportation p by Common Shipment Carrier Destination o Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom H 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 09/29/2023 Registrar of Vital Statistics Dixie Lee Leblanc(Electronically Signed) (signature) District Number 2056 Place Town Of Long Lake I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition ?-,gO.- i; Place of Disposition P;,J e ',e,,,) Cry ,c/o c- W 2 (address) W N IX (section) (lot number) (grave number) aName of Sexton or Person in Charge of emis e ,\ n ri &iA/ ) LJaaC4 Z (please print) IliSignature �` «/.. Title CVO-A)4 DOH-1555(07/18)p 1 of 2 O1 326 Public Health Law Sec. 4145(2b) .` �//' r....... 4 Receipt Human remains of �� -siiiiim , 20 �f° delivered on f° �.,." !I' r : / z ;� t Pine�ew Cemetery ^� � � , Official Representing the funeral home named on burial Permit Funeral Directors Reg.or License#