Travis, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas Travis Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/18/2015 65 years War or Dates No
j- Place of Death Hospital, Institution or
Ritodown or Wilton Street Address 9AR NnrthPrn Pins Rd
f Manner of Death Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined El Pending
ua Circumstances Investigation
ill Medical Certifier Name Title
CI Michael Sikirica Md
Address
50 Broad Street Waterford Ny 12188
Death Certificate Filed District Number Register Number
down or\MINX Wilton 4569 6
. ❑Burial Date Cemetery or Crematory
❑Entombment 01/21/2015 Pine View Cemetery
Address
;:.:N[ remation Queensbury
Date Place Removed
Z Removal and/or Held
9❑and/or Address
CA
Date Point of
IZ Transportation Shipment
C by Common Destination
gi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiiig Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
iig Address
402 Maple Ave. Saratoga Springs N Y 12866
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
I
ILI
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/21/2015 Registrar of Vital Statistics !l/f//�/k�` "
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District Number 4569 Place Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k''
1Lt Date of Disposition I/ZZMir Place of Disposition g,,L G- i3:
2 (address)
I<it
to
re (section) (lot number) (grave number)
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ct Name of Sexton or Pe on in Charge of Premises .- St^At
Zr (please print)
la Signature �? L Title n%,l+1tfON
(over)
DOH-1555 (02/2004)