Collins, Thomas NEW YORKC STATE DEPARTMENT OF HEALTH
Vital Records Section Rurua - Tra ' tt
Name First Middle Last Sex
Thomas Patrick Collins
,h' Date of Death Age If Veteran of U.S.Armed Forces,
1/10/2017 49 Vier or Dates
• Place of Death Hospital, Institution or
City X lttt lQlit Glens Falls Street Address G i enuj a l l c H ns p i t a l
Manner of Death ED Natural Cause Accident ❑Homicide 0 Suicide 0 y�q �
• Medical Certifier Name Title
Eric Pillem4Ir M.D.
� Address ,,
%, 100 Park St. Glens Falls NY 12801
Death Certificate Filed District Number Regisfer Nuns 0
City,irdlittdMr1051140 G1 ens Falls 5601
, Burial
Date Cemetery or Crematory
LJEss
nt� �mbinent _ 1/11/2017 Pi nev i ew Crematorium
r:Crema i 21 ivaker Road tueensbur ► :r,
Date Place Removed
Removal
and/or Held
anWor
f Hold r. Address
,,
Date Point of -
'7 Transportation Shipment
", by Common Destination
Carrier
s Date I Cemetery Address
,. Ds
fteinterreent Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Radloff Funeral Home Inc. 1425
P Address
` 136 Warren Street Glens Falls New York 12801..
• Na• me of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
I Address
` Permission is h _ y gram described
to dispose at the human ns above as in
Date Issued ci ii f f Registrar of Vital Statistics
/, nature)
District Number �Ga(.? � Ply fs0 �:t-.�? >7
l certify that the remains of the decedent identified above wer disposed of in scar. • ..: with this permit on:
4
Date of Disposition (1(L(/7 Place of Disposition P4tti...., �a'-4 "'
-":
iiil (section) p _ tnumbeS— (grave n )
Name of Sexton or Personin Charge of Premises Gore . `"' +
IPl
Signature Title Cr1411-1)+t
(over)
DOH»1555(0 2004)