Thornton Sr., Stanley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stanley William Thornton,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 13,2012 56 War or Dates N/A
':: Place of Death Hospital, Institution or
°' City.;"Town or Village Poughkeepsie Street Address Vassar Brothers Medical Center
Manner of Death I XI Natural Cause I I Accident [ I Homicide Suicide 1 Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0 Muhammad Bashir MD
44,, Address
q 45 Reade Place Poughkeepsie,NY 12601
;a D.gath,Certificate Filed District Number Register Number
City,.Town or Village City of Poughkeepsie �`
�Burial Date Cemetery or Crematory
January 17,2012 , Pine View Cemetery
0 Entombment Address
❑Cremation Quaker Rd. Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
y I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
`r:g= Permit Issued to Registration Number
°=mk Name of Funeral Home Carleton Funeral Home,Inc. 00281
Address
_, 68 Main Street, P.O. Box 67,Hudson Falls, NY 12839
ni Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
Address
•
„.,: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (PI�( -;_2'i Registrar of Vital Statistics C�`[;i.t(L t � i' �_SC.t✓C C,_:.
I(signature)
District Number 1 )
X�, Place City of Poughkeepsie
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1 /1 8/1 2 Place of Disposition Pine View Cemetery
Ill
2 (address)
� Huron 14E 1
(section) (lot number) (grave number)
Z Name of Sexton or Perso in Charge of Premises Mi r•haPi C;en i Pr
(please print)
ILI
Signature ' f1n0A-4/`. Title Superintendent
(over)
DOH-1555 (02/2004)