DeGroff, Thomas NEW YORK STATE DEPARTMENT OF HEA i7f C--
TH Burial - Transit Permit
Vital Records Section ,
Name First 'l'4ddle Last Sex
Thomas G. DeGroff Male
Date of Death Age If Veteran of U.S.Armed Forces,
1„ April 18, 2006 , 73 War or Dates /9S/- /9,.53
Z Place of Death Hospital, Institution or
ig City,Town,or Village Fort Edward Street Address 325 Broadway Apt. 13
0 Manner of Death n Natural Cause El Accident El Homicide El Suicide ❑Undetermined 0 Pending
w Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Max Crossman MD
0 Address I
79 North Street, Granville, NY 12832
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 7, '1 45'
n Burial Date Cemetery or Crematory
1a 17IA 6 Pineview Crematorium
n Entombment Addres
Cremation Queensbury, NY
Date Place Removed
0 n Removal and/or Held
. and/or Address
f Hold
0 Date Point of
0 EI Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
On Disinterment
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00931
Address
46 Williams Street, Whitehall, New York 12887
F= Name of Funeral Firm Making Disposition or to Whom
$
it Remains are Shipped, If Other than Above
W Address
8.
Permission is a eb granted to dispose of the human r ains described above as ndicated. ��
Date Issued __ �9 �f Registrar of Vital Statistic t .L/� � �
(signature)
District NumbeL75i Place Fort Edward,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
LI Date of Disposition "1- .O1 Place of Disposition Pineview Crematorium
2 (address)
LI
t)
4 (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises a 10Lb f2,— G)--Ai' , ---
Z (please print)
Ill
Signature G_62 0,/,/,,,(, Title 6'(L am A 12._
(over)
DOH-1555 (02/2004)