Purdy, Thomas it g
NEW YORK STATE DEPARTMENT OF HEALTH ZO
Vital Records Section Burial - Transit Permit
o Name First Middle Last ' Sex
Thomas A. Purdy Male
Date of Death Age [If Veteran of U.S. Armed Forces,
10/14/2018 65 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
- Manner of Death X Natural Cause i Accident j Homicide j Suicide j Undetermined - Pending
f
Circumstances Investigation
,' 1 Medical Certifier Name Title
t. Shahid Ahmed MD
TM Address
" ' 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number T Register Number
City, Town or Village Glens Falls 5601 1 485
6_E tombment Date/12o1a 5 Cemetery or Crematory
-- Pineview Crematorium
Address
X Cremation Queensbury Town, New York
Date Place Removed
N Removal
and/or Held
and/or
Address
Hold
Date Point of
� `: ; Transportation Shipment
‘ by Common Destination
'f: Carrier
A H ' Disinterment Date Cemetery Address
Ali�h Date CemeteryAddress
Reinterment
4 Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home i_01117
14 Address
18 George St Po Box 277, Fort Ann, New York 12827-0277
'4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
�t Address
Permission is hereby granted to dispose of the human remains described above as indicated.
4
A'i Date Issued 10/15/2018 Registrar of Vital Statistics Robert A Curtis(E(ectronicauly Signed)
(signature)
f District Number Place
5601 Glens Falls, New York
1M2
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
_ Date of Disposition /0 Place of Disposition L l�t
± ?I, (address)
(section) (lot numbe (grave number)
; � 5 Name of Sexton or Person in Charge of Premises '+,' .� r•+✓'r
(please print)
Signature Title (fit'
(over)
DOH-1555 (02/2004)
i