Thomas II, Francis NEW YORK STATE DEPARTMENT OF HEALTH ti.' 22
Vital Records Section Burial - TransitPermit
(<`s==r Name First Middle Last Sex
Grr" Francis Nelson Thomas,II Male
l Date of Death Age If Veteran of U.S. Armed Forces,
lfF"f.Y January 4, 2017 80 War or Dates Airforce
`Yifl*J
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 18 Farr Lane
Manner of Death L Natural Cause Accident n Homicide Li Suicide Undetermined n Pending
41 Circumstances Investigation
Medical Certifier Name Title
William Parker,MD
Address
5 100 Broad Street, Glens Falls,NY 12801
'' Death Certificate Filed District Number Regis Number
r. City, Town or Village Queensbury
❑Burial Date Cemetery or Crematory
January 9, 2017 Pine View Crematorium
❑Entombment Address
❑X Cremation 51 Quaker Road,Queensbury, NY 12804
Date Place Removed
Z —Removal and/or Held
O —and/or Address
E Hold
U)
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
`s Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
A• ddress
,> 4• 07 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
IRemains are Shipped, If Other than Above
Address
y Permission is hereby granted to dispose of the human rem n d scr' ov 'ndi d.
Date Issued I— (p-db 1l1 Registrar of Vi Statistics 0
gnature
D• istrict Number .1S1Place . A '
•
I certify that the remains of the decedent identified above wer. dispo ed of in accorda e wit this permit on:
Z
LU Date of Disposition //zl/ 7 Place of Disposition � ie 1)y' ,J 6 4. d'
// (address)
W
N
O (section) / (lot number) (grave number)
pName of Sexton in Charge of Premises (A.ha ✓i 66 ono 04-e
`Z (please print)Signature Title C d er-e,4
(over)
DOH-1555(02/2004)