Fuller, Thomas NEW YORK STATE DEPARTMENT OF HEALTH ,l,
Vital Records Section , ,.. ._. s Burial - Transit If Permit
Name First Middle Last Sex
Thomas Matthew Fuller Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/18/2018 43 Years War or Dates
Place of Death Hospital, Institution or - —
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death® Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
—I Medical Certifier Name Title
er Suzanne Bergin DO
Address
=3 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 96
OBurial Date Cemetery or Crematory
02/26/2018 Pine View Crematorium
Q Entombment
., Address
Cremation Queensbury Town, New York
iDate Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
ox El Transportation Shipment
5 by Common Destination
Carrier
'' �Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
',FF Name of Funeral Home Carleton Funeral Home Inc 00281
': Address
's 68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/20/2018 Registrar of Vital Statistics Robert A Curtis(EIectronicaftySigne
(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:
W Date of Disposition 2/19III Place of Disposition etc iii:,,, 4,4:
W (address)
d (section) 4 (lot numbs/) (grave number)
Name of Sexton or Person in Charge of Premises (4114i1- J' 'it
/�� (p se •
print)
Signature Lr( Title +tlL
(over)
DOH-1555(02/2004)