Tyminski, Thomas NEW YORK STATE DEPARTMENT OF HEALTH ..- sG
Vital Records Section Burial - Transit Permit
:.' Name First Middle Last Sex
Thomas James Tyminski Male
:` Date of Death Age If Veteran of U.S. Armed Forces,
March 22, 2018 65 War or Dates
Place of Death Hospital, Institution or
ut City, Town or Village Kingsbury Street Address 1092 Dix Ave
1 Manner of Deathini Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
.,. Circumstances Investigation
Medical Certifier Name Title
,„„F Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
' Death Certificate Filed District Number Register Number
City, Town or Village S 76 2
R1,❑Burial Date Cemetery or Crematory
March 26, 2018 Pine View Crematorium
❑Entombment
Address
.®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
r' Hold
" Date Point of
❑Transportation Shipment
XO by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
�,E Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
4 Name of Funeral Firm Making Disposition or to Whom
° Remains are Shipped, If Other than Above
Address
w
.a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/�� / / Registrar of Vital Statistics ti,, (Z- 144,
(signature)
i District Number 6-76)- Place 70ur► 01 ,s its s 6uiy
~ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/26/2018 Place of Disposition Quaker Road Queensbury,NY 12804
:: 3i (address)
(Ct (section) (lot nur) (grave number)
A01
L'3,, Name of Sexton or Person in Charge of P emises ..,�+� t+�
(please print)
Signature �►T Title ( liglA
(over)
DOH-1555 (02/2004)