Gothey, Thomas C. NEW YORK STATE DEPARTMENT OF HEALTH N YOJ
Vital RerAmaEewnn - Burial - Transit Permit
Name First Middle Last Sew
Thomas C. Dinner Male
Data of Death Age If Vehren of U.S. Am
ore Forced,
AanI 17 2021 0] Warm Omer
place of DeeN HWgi e, innuendo or
City Town or Village Fort Etlwam Slrem Address 2408roedway Fort E rd
Manner of DeaM 0 Natural Cause ❑ Aacidertt ❑ Hormone❑ Suicide ❑Circumstances ❑ pandINIneeditip tiafl
Maoral Certifier Name Title
Sheran Sharron NP
Address
9 Carry Read Cunene u NY 12001
Death Certificate Films District Numb®' Register Number
Cav Team or ViTine Fort Eckam 09
❑Bunal OaN Cemmery or Crematory
MW 26, 2020 Pine Mee Commodity
❑ErMmbrnent Address
®Cremation Quaker Read QuaderalownyNY 128M
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❑ Disinterment DaN Cemetery Address
❑ Remewment Date Cemetery Address
Permit Issued to ModernRegi Number
Nance of Funeral Home M. S. Kilmer Funeral Home FE O1079
Morass
82 Broadway Fort Emi am NY 1282a
Name of Funeral Firm Making Disposition or to Whom
Remains are Stripped, If Other Man Above
Address
Permis lMwh reby medta tllapaaa of iM1a M1uman sdDecHba ab •ae ' dkmed.
Date Issued RegistrarINVlbl BlaasmA
Distract Numberm5tL pla cii� (LLU
I certify that me remain or the decedent Mandel abrna were diaeasen of in accordance arm thus Permit on:
ry Date of Deformation gfti WO20 platy at Dis"Ition Quaker Rog] Oueensbury.NY 128M
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W2 y( (Season / lwm.+w+n C 1pary mwwad
Name of Sexton or Person in Charye Preml L �rU1s�s• JwwsM
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Sand TitN k
(dean
DOH-1555 (022004)
Nblic HeaIN Law Sec. 4145(26) 013876
Receipt
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