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Headlee, ThomasF 0_3 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Male Thomas Russell Headlee Uate oT Ueath Age ft Veteran. ot.U.b..Armed.I-omes, 10/12/2019 62 Years War or Dates Place of Death Hospital, Institution or Town Warren Street Address 68 Maple Lane, Chester Town Warren, New York 12817 d City, Town orVillage Chester Manner of Death Undetermined Pending © Natural Cause Accident Homicide Suicide ❑ Investigation W Circumstances 0 Q IAle Medical Certifier Name MD Paul Bachman Address New York 12804 9 Carey Rd, Queensbury Town�aerto��� Death Certificate Filed District Number Register Number 565216 City, Town orVilla a -Burial Date Cemetery, Crematory or Facility Name 10/15/2019 Pine View Crematorium Entombment Address 0 Cremation Queensbury Hamlet, New York PDonation . r flats PlarP Rcm---- U Hemoval and/or Held and/or Address E IHold Date Point of ❑Transportation Shipment by Common %airier Date Disinterment Cemetery Address ElReinterment Date Cemetery Address Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St, Chestertown, New York 12817 Name of Funeral Firm Making Disposition or to Whom IF-1 Remains are Shipped, If Other than Above Nuuirr`� IIr W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/14/2019 Registrar of Vital Statistics Mindy Conway (ECectronicaQysign /signature) Uistrkl Number 5652 f'tace Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition to Place of Disposition ft.tf ," " ; ,� W (address) it 1 Im (sectan) / number) (grave number) Z W Name of Sexton or Person in Charge of Premises aj OL Ix (ple print) Signature Title 1)014-i5" fmlif3l n l of 2 PUBLIC HEALTH LAW § 4145. Deaths; burial and removal permits; disposition of remains. L No person in charge of any premises on which iirier►nenis, c►en►airv►►s u► vii►er vispusiiiur► interment or other disposition of any body ui lire 6U4 of a ueLeased persoar n e made WWII inier u► perrrrii ilre in this article. ss it is accompanied by a burial, cremation or transit permit, as provided 2. (a) The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition before interring or otherwise disposing of the body or shall attach the removal or transit permit to the box containing the body, when shipped by any transportation company, which permit shall accompany the remains to its destination, where, if within this state, it shall be delivered to the person in charge of the place of burial or other disposition. b) Any person or other entity owning, operating, managing, or designated to receive the body of a deceased person at a Place Ofitldri;* C_re!Tl tim or other final dispn5ition in this state� Why. Each � rerQivQs tha hn1. rly of ? r♦pcpacpd nPrcnn, shill provide a receipt for the body to the funeral director, undertaker or registered resident who delivered such b receipt shall (i) be endorsed by both such person and the funeral director, undertaker or registered resident, (i ►and sate the date the body was delivered, (iii) include the name of the funeral director, undertaker or registered resident delivering the body and the registration number of such funeral director, undertaker or registered resident, (iv) include the name of the registered funeral firm the funeral director, undertaker or registered resident represents, (v) include the name nr 'he deceased person as ii appears on the burial, cremation, or fransh permif, and (vi) include ine name of the owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition who received the body of the deceased person. A copy of such receipt shall be retained by the owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition for a period of not less than four years, and shall be made available for inspection by the division of cemeteries during normal business hours. The original copy of every such receipt shall be retained by the licensed funeral firm for a period of not less than four years pursuant to the rules and regulations of the department governing the maintenance of records. 3. The person in charge of the place of burial or other disposition shall endorse upon the permit, the date of interment, or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of interment, cremation or other disposition. 4, When burying or ntherwkp dismosing of the body Of a deceased person in a fP►l7PterV or burial place h'lV1�1O !tO person in charge, the funeral director or undertaker shall (a) sign the burial or removal permit, giving the date of burial; (b) write across the face of the permit the words "No person in charge; " and (c) file the burial or removal permit within three days with the registrar of the district in which the cemetery is located. 5. The person in charge of the place of burial, cremation, or other disposition shall keep a record of all bodies interred or merwise disposed or on Ule premises _under his rnarge, in earn Casesiaiing-ire name of each deceased person, pierce of death, date of burial or disposal, and name and address of the funeral director or undertaker, which record shall at all time be open to official inspection. DO H-1555 (07/18) p 2 of 2 Public Health Law Sec. 4145(2b) 012598 Receipt Human remains of Pine View Cemetery representing the funeral home nai6d on burial per 't Official Funeral Directors Reg. or License # 4-1- - -