Rowe, Thomas r
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Thomas James Rowe Male
Date of Death Age If Veteran of U.S.Armed Forces,
October 19, 2013 22 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Wilton Street Address 2 Pulver Blvd.
pManner of Death ❑Natural Cause Accident Homicide QX Suicide n Undetermined Pending
Circumstances Investigation
tii Medical Certifier Name Title
CI Michael Sikirica
Address
579 Grand Ave,Saratoga Springs,NY 12850
Death Certificate Filed District Number Register Number
City,Town or Village Town of Wilton
®Burial Date Cemetery or Crematory
❑Entombment October 23,2013 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,,NY 12804
Date Place Removed
Z 0 Removal and/or Held
p and/or Address
H Hold
co
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
N Remains are Shipped, If Other than Above
2 Address
fit
Wa.
Permission is hereby ranted to dispose of the human rem ins described above as indicated.
Date Issued 7
�(� `( / Registrar of Vital Statistics rCd
(signature)
District Number Li'3 6 Cf Place Town of Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z r
LU Date of Disposition e.t ,3,(3 Place of DispositionPo/Le,'
1,ij ikejj J pipAi
w &Lt._ (eddies)
CO
Lt
0 (s9eg on) (lot number) (grave number)
Name of Se n or Person in Charge of Premises L-011 1Z f t_ /_. C;L�C-_7�. i
ui
Z lease print)
Signature / k�, Title pheAr @al1.>:
V
(over)
DOH-1555(02/2004)