Toole, John . -q bb7
NEW YORK STATE DEPARTMENT OF HEALTH „Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
,A John A. Toole Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/20/2018 68 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village S. Glens Falls,NY Street Address 4 Brentwood Drive S.Glens Falls,NY
Manner of Death Natural Cause —Accident (- Homicide T.Suicide in Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
et` Aqeel A. Gillani MD
Address
102 Park St.Glens Falls,NY12801
Death Certificate Filed District Number �,Z Register Number J
City, Town or Village South Glens Falls,NY If
0 Burial Date Cemetery or Crematory J
Entombment Address
26, 2018 Pine View Crematorium
0 Address
Ni Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
2 and/or Address
H Hold
U _
0 Date Point of
N E Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
iiii
Permission is hereby ranted to dispose of the human remains des i d above as indicated.
Date Issued Registrar of Vital Statistics
(signature)I
District Number 45 L Place V /(a 62fSP,(4 6-6/132
T Ll
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /a
am
� Date of Disposition lb/�(d i
Place of Disposition 4� ( r
LU (address)
Cl)
p0 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of/Premises tl rk %r S ,�,,,.,,,,�,id
Z (pl ase print)
W Signature , Title lig:41.3.4.
(over)
DOH-1555(02/2004)