Lamphere, Thomas NEW YORK STATE DEPARTMENT OF HEALTH ' 1 g3iW
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas Darwin Lamphere Male
Date of Death Age If Veteran of U.S.Armed Forces,
1. May 21, 2017 92 War or Dates
2 Place of Death Hq i*Institution or
W City,Town,or Village Whitehall Street Address His home
G Manner of Death V1 Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Julie Foster, M.D. Dr.
a Address
275 Route 30N, Bomoseen, VT 05732
Death Certificate Filed District Number 071f'(jj Register Number i
City,Town or Village Whitehall O
❑Burial Date Cemetery or Crematory
May 23, 2017 Pineview Crematorium
❑Entombment Address
Q Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
in and/or Address
I' Hold ,
Date Point of
0 ❑Transportation Shipment
i by Common Destination
Carrier
Date Cemetery Address
0 ❑Disinterment
III Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
x▪ Remains are Shipped, If Other than Above
W Address
0.
Permission is herebyri granted to dispose of the human remains described above as indicated.
Date Issued 6MIi Q j 7 Registrar of Vital Statistics \ a. T Zr<�&M
111111______'''"' (signature)
District Number SILO t Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 05/23/2017 Place of Disposition Pineview Crematorium
2 (address)
la
0 0 (section) (lot number) . (grave number)
Name of Sexton or Person in Charge of Premises l/ ,�i ,;- i no r 1r
W �n(please print)
Signature '' Title ('REpi tiO
(over)
DOH-1555 (02/2004)