MacJarrett, Thomas 5 'I3
NEW YORK STATE DEPARTMENT OF -IEALT#-1
Vital Records Section Burial - Transit Permit
l:, Name First Middle Last Sex
Thomas M. MacJarrett Male
"' Date of Death Age If Veteran of U.S. Armed Forces,
f July 29, 2017 60 War or Dates Iran-Iraq War
t`'`� Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death ❑Natural Cause X Accident ❑Homicide Suicide n Undetermined Pending
Circumstances Investigation
Cki A Medical Certifier Name Title
Fl! Terry Comeau Coroner
Address
Lake George,NY 12845
10 Death Certificate Filed District Number Register Nu upper
City, Town or Village Glens Falls 5601 [� Y
El Burial Date Cemetery or Crematory
August 4, 2017 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
�' Hold
N
0 Date Point of
Nn 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
f' 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 tZi Zb(7 Registrar of Vital Statistics W`A,ky\si.
(signs ure)
District Number 5601 Place Glens Falls, y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 4 /7 Place of Disposition J rs4.✓1 iceyri
W (address)
co
0 (section) (lot number) (grave number)
Q Name of Sexton r P s n in Charge of Premises Jt, f,a... G'4,.014c.. .4
IZ (please print)
Signature Title Cpe.j,.1 /
(over)
DOH-1555(02/2004)