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Story, Thomas Frederick NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas Frederick Story Male Date of Death Age If Veteran of U.S.Armed Forces, 01/11/2020 66 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Hartford Town Street Address 7767 State Route40,Hartford Town,New York 12838 p Mannerof Death ©Natural Cause Accident Homicide Suicide ❑Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title Wesley Perry Coroner Address 415 Lower Main Street,Hudson Falls,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Hartford 5759 5759 Burial Date Cemetery,Crematory or Facility Name 01/21/2020 Pine View Crematorium Entombment Address ICremation Queensbury Town,New York ❑Donation ❑Removal Date Place Removed and/or and/or Held N Hold Address O IL Date Point of 0 ❑Transportation Shipment p by Common 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 H Remains are Shipped,If Other than Above Address cr W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/14/2020 Registrar of Vital Statistics Denise Petteys(ECectronicaCCySigned) tignature) District Number 5759 Place Hartford, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition �� It 110 Place of Disposition 'I ��..i (v— Lu (address) W N /section) (lot numb (grave number) cc a Name of Sexton or Person in Charge of Pre ises �" � !ti`^i '` /please print) W Signature Title ru 1h ft DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 1-3 2 6 7 Receipt Human remains of ` delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#