Lawson, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
in. Name First Middle Last Sex
Thomas Matthew Lawson Male
• xx Date of Death Age If Veteran of U.S. Armed Forces,
'a September 13,2012 84 War or Dates No
• R° Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
1 Manner of Death n Natural Cause n Accident n Homicide n Suicide Undetermined Pending
Lit Circumstances Investigation
Medical Certifier Name Title
' Michael Fuller
Address
' 100 Park St,Glens Falls,NY 12801
• _: Death Certificate Filed District Number Register Number
• :: City, Town or Village Glens Falls 5601 (4 21
1 Burial Date Cemetery or Crematory
❑Entombment 9-18-12 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z n Removal and/or Held
O and/or Address
F' Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
: 407 Bay Road, Queensbury, NY 12804
n Name of Funeral Firm Making Disposition or to Whom
k* Remains are Shipped, If Other than Above
N1 Address
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued I l '—I)iZ Registrar of Vital Statistics w , �w_A ,
I (signature)
District Number 5601 Place Glens Falls
~ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 9/1 8/1 2 Place of Disposition Pine View Cemetery
(address)
y Erie 64A 3
QCL (section) (lot number) (grave number)
Name of Sexton or Perso in harge of Premises Michael Genier
Z (please print)
W Signature Title Superintendent
(over)
DOH-1555(02/2004)