Hall, Thomas IIIN 103
6:
NEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Burial - Transit Permit
Name First Middle Last Sex
Male
Thomas Carmy Hall III
Date of Death Age If Veteran of U.S. Armed Forces,
10/21/2019 75 Years War or Dates
Place of Death Hospital, Institution or
Street Address Glens Falls Hospital
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W
p
City, Town or Village Glens Falls
Manner of Death Undetermined Pending
Natural Cause Accident Homicide Suicide ❑
Investigation
W
Circumstances
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Medical Certifier Name Title
William Cleaver MD
Address
100 Park St, Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 458
Burial Date Cemetery, Crematory or Facility Name
10/25/2019 Pine View Crematory
Entombment
Address
aCremation
Queensbury Town, New York
Donation
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Removal
Date
Place Removed
0
and/or Held
and/or
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Hold Address
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Off.
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Date Point of
Transportation
Shipment
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by Common
Carrier
Destination
Disinterment
Date
Cemetery Address
JE]Reinterment
Date
Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Maynard D Baker Funeral Home
01130
Address
11 Lafayette St, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
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Remains are Shipped, If Other than Above
2
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/21/2019 Registrar of Vital Statistics $',n6ert,;n�rewCurtif �E'le�tromi7alySo zw)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition It t%I f1 Place of Disposition zxj t/r�wtar•J~
(add s/
2
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(section) (lot number/ (grave number)
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Name of Sexton or Person in Charge of Premises �J t��1ifi
(plea print)
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Signature Title ��-
DOH-1555 (07/18) p 1 of 2
Public Health Law Sec. 4145(2b) `
Receipt
Human remains of
Pine View Cemetery
Official
013028
delivered on 120
Representing the funeral home named on burial permit
Funeral Directors Reg. or License # ; + ;