Azer, Thomas NEW YORK STATE DEPARTMENT OF HEALTH v 1 4 Z g7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas Brown Azer Male
Date of Death 0 4/0 6/2 01 8 Age 8 9 If Veteran of U.S. Armed Forces,
War or Dates 1 9 5 5-1 9 81
Place of Death Hospital, Institution or
„ City, Town or Village Queensbury Street Address 11 Pinion Pine Lane
Manner of Death 17 1Natural Cause El Accident El Homicide D Suicide ri Undetermined ri Pending
Circumstances Investigation
4
Medical Certifier Name Title M.D.
Paul Filion
Address
3 Irongate Center, Glens Falls, NY 12801
- Death Certificate Filed District Number Register Number
City, Town or Village SArS1 LFg.
',nip Burial Date 04/09/2018 Cemetery or Crematory Pine View Crematory
❑Entombmentzig Address
_'®Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
1❑Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
y Permit Issued to Registration Number
Name of Funeral Home Wilcox $ Regan 01 821
Address 11 Algonkin Street, Ticonderoga, NY 12883
• i_ Name of Funeral Firm Making Disposition or to Whom
w Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued t-I.-i-a.01 g Registrar of Vital Statistics ,,o,i.Z_ -4LN.t. t t ,\.1
(signature)
' District Number S G 1 Place Q U CC Y1S bur3
Ott
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition y/rte Place of Disposition ?, - L Gruen //(address)
(section) i (1 t number) (grave number)
Name of Sexton o erso in Charge of Premises
(please print)
:� Signature A Title �' "-Al
(over)
DOH-1555 (02/2004)