Spaulding, Thomas 0 - 4t 711_
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Thomas Charles Spaulding Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/10/2018 75 War or Dates Navy
1. Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 3 Owen Ave
m Manner of Death ❑ ❑ ❑ E n Undetermined Pending
Natural Cause Accident HomicideSuicide
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson,PA
Address
Queensbury,NY
Death Certificate Filed District Number moister Number
l'
City, Town or Village Queensbury,NY 5657 C S-
❑Burial Date Cemetery or Crematory
❑Entombment November 13,2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZC ❑Removal and/or Held
and/or Address
H Hold
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O Date Point of
y ❑Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
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
Address
ILI
• Permission is hereby granted to dispose of the human re ains describe above as indicated.
' Date Issued\ 0 1.,;\ bINS2Registrar of Vital Statistics C� Q c .,-, __ ,_
(signature)
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District NumbeQ0c—) Place ( 0 -y_, Lls49 ,�
I certify that the remains of the decedent identified above were disposed of in accor nce with this permit on:
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W Date of Disposition Al ILI l(Y Place of Disposition '�i.. ,_.., /-t- 0ot -(address) ,
W
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CZ (section) 4 tacit nu ber) (grave number)
pName of Sexton or Person in Charge f Premises (An1 t� ati&(
(p14ase print)
W Signature 1, i_. Title alfrovit17
(over)
DOH-1555(02/2004)