Thomas, A. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
iilililil Name First Middle Last Sex
A. Coolidge Thomas male
Date of Death Age If Veteran of U.S.Armed Forces,
9/6/88 76 War or Dates no
Place of Death Hospital, Institution or
k City,Town or Village City of Glens Falls " Street Address Glens Falls Hospital
.i .Cause of Death
........................................................ . ....
acute myocardial infarction
ti Medical Certifier Name Title
€G Robert Reid MD
Address:::::.......................................................................................................................................................................................................
8 Harrison Avenue, Glens Falls, New York 12801
Death Certificate File:::::.................................................................. .............................................. . .....................
..............................................
d District Number Register Number
>€ City,Town or Village City of Glens Falls4fl T
Date Cemetery or Crematory
Eg 0 Burial
Em /
❑Cremation > Address
Town of Queesnbury, N.Y.
..............z ..........:> Date:::::...................................................... ......:::::Place Removed
Q; ❑ Removal and/or Held
and/or Hold :::::::::::::::::::..::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::>::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::,:::::::::::::::::.::::::::::::::::::::::::::::::::::::
r: Address
la
a
Date Point of .....................................
: .............
:::::::::::::::::::::::::::::.
'
rn: ['Transportation by Shipment
Common Carrier
Destination
.......................................... Cemetery::::::Date
.:::::.......................................................:::. Address
::::::...................................................................................................
❑ Disinterment
..........................................:.:::::Date':::::.....................................................::..::.Cemetery Address:::::................ ..............................................................................
IP ❑ Reinterment
iiiig Permit Issued to Registration Number
s' ?' Name of Funeral Firm Re an and Denny Funeral Service, Inc. 02883
Address
40 Quaker Road, Glens Falls, N.Y. 12801
Name of Funeral Firm Making Disposition or to Whom
mi Remains are Shipped, If Other than Above
.............................................................................................. .......
Address
AU.............................................................................................................
IMi Permission is hereby ranted to dispose of the human re ains described above as indicated.
Date Issued Registrar of Vital Statistics iR--4.01 .9- A.A.12,...? 6/,.,
(s. nature) y �f��
iNi District Number3 J/ Place A ' /(//` , `71 .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
`N;
W Date of Disposition l.- -- Place of Disposition .t rs ' �` -_ • v +-v�
(adjddress) + J
�: (sedioort) (lot number) (grave number)
I . Name of Sexto er rson in Charg Premises 64 @ S
z (please print) --,,
W Signature (3; ?41Ai
^- .CsX�;a Title s
DOH-1555(9/86)p 1 of 2(formerly VS-61)