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Gosch, H. Kendall Jr.
40 �`A Ig..\ •tt 3 NEW YORKSTATE DEPARTMENT OF HEALTH /� Bureau of Vital Records , Burial - Transit Permit Name First Middle Last Sex H.Kendall Gosch Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 12/05/2023 90 Years War or Dates Marine Corps i.. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death a Natural Cause Accident Ej Homicide Suicide Undetermined Pending Circumstances Investigation WG Medical Certifier Name Title Robert Reeves MD Address 3 Irongate Center,Glens Falls,New York 12801 -0., Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 575 ' Date Cemetery,Crematoryor FacilityName Burial 12/11/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury,New York Donation 0❑Removal Date Place Removed F. and/or and/or Held a Hold Address 2 Date Point of I)❑Transportation ZS 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 F. Remains are Shipped,If Other than Above 2 Address C W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/11/2023 Registrar of Vital Statistics rteganWolin(ECectronicaCCySigned) (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: Date of Disposition j2111 I 73 Place of Disposition FI,,PkC-PC OXIMiresy4--. 2 (address) W CO 8 (section) ilet)tc (iot number) (grave number) Name of Sexton or Person in Charge of Prem. s �. n ff fZ (pse print) /�, Ill Signature Title r'`�G/r11�ter DOH-1555(07/18)p 1 of 2 1 774 3. Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Fine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#