Boisvenue, Thomas II Syr
NEW YORK STATE DEPARTMENT OF HEALTH f
Vital Records Section f v Burial - Transit Permit
Name First Middle Last Sex
Thomas Albert Boisvenue Male
,., Date of Death Age If Veteran of U.S. Armed Forces,
``' 11/07/2017 64 Years War or Dates
oft
.ter Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Jean Vanauken PA
Address
100 Park St,Glens Falls,New York 12801
-4 Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 574
'--' Date Cemetery or Crematory
-.��❑Burial
11/08/2017 Pine View Crematory
,. El Entombment Address
,:A Enn
®Cremation Queensbury Town, New York
,7119
Date Place Removed
- ❑Removal and/or Held
and/or
Address
Hold
µ Date Point of
❑Transportation Shipment
ate; by Common Destination
Carrier
o❑Disinterment Date Cemetery Address
El Renterment Date Cemetery Address
Permit Issued to Registration Number
_ Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
:;, Name of Funeral Firm Making Disposition or to Whom
=ram Remains are Shipped, If Other than Above
Address
t1
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/08/2017 Registrar of Vital Statistics [4g6ertACurtis EternvmcaaySigned
(signature)
District Number 5601 Place Glens Falls, New York
'" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
T Date of Disposition ii 113 111 Place of Disposition `I"t U.,,,.i irkmktoP....
(address)
1"
(section) i(lot number) c ,1e (grave number)
` Name of Sexton or Person in Charge of Premis pi
htu 3L44 s"I
(pe print)
g M ATT1�
Signature Title
(over)
DOH-1555 (02/2004)