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O'Donnell, Thomas James f , #(, NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas James O'Donnell Male Date of Death Age If Veteran of U.S.Armed Forces, 01/17/2020 79 Years War or Dates 1960-1964 F Place of Death Hospital,Institution or Z City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare W Manner of Death Undetermined Pending � © Natural Cause Accident ❑Homicide Suicide g W Circumstances Investigation W Medical Certifier Name Title Edit Masaba MD Address 4573 State Route 40,Argyle Town,New York 12809 Death Certificate Filed District Number Register Number City,Town or Village Argyle 5750 3 Burial Date Cemetery,Crematory or Facility Name 01/21/2020 Pine View Crematorium Entombment Address Cremation Queensbury Town,New York ❑Donation OZ Removal Date Place Removed and/or and/or Held ~ Hold Address N O a. Date Point of N Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address ir W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/20/2020 Registrar of Vital Statistics ShetFey Yckernon(ECectronicaffy Signed (signature/ District Number 5750 Place Argyle, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H ` Z Date of Disposition //21 I to Place of Disposition ca. / r�.► LU (address/ W N (section) _(lot numbed (grave number) 0 Name of Sexton or Person in Charge of Premises "' It} � lease print) Zto Signature ZJ Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on t- , , 20 -., Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#