Thomson, Carol 711
NEW YORK STATE DEPARTMENT OF HEALTH _'•'�•Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carol L. Thomson Female
.f f Date of Death Age If.Veteran of U.S. Armed Forces,
April 5,2017 46 War or Dates NA
Place of Death Hospital, Institution or
• City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
: Manner of Death Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Scott Biasetti MD
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number ��� Register Number
City, Town or Village Glens Falls, NY L..JJ 0?/1
'❑Burial Date Cemetery or Crematory
April 7, 2017 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
Hold
t/)
0 Date Point of
Transportation Shipment
p by Common Destination
Carrier
❑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
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Li t l 1 Registrar of Vital Statistics W
(signatur
• District Number 5 c,3 I Place 6 (Q.A.� S l 1 S ,3 y.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uDate of Disposition 11111 1 11 Place of Disposition fi ttALL-.
LiJ (address)
N
(section) / (lot number) (grave number)
pName of Sexton or Person in Charge of Premises �11r.1 Sl+�ltf�'
Z (pl ase print)
W Signature � Title
(over)
DOH-1555(02/2004)