Hughes, Thomas NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas Porter Hughes Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 24,2017 71 War or Dates n/a
° Place of Death Hospital, Institution or
City, Town or Village Manner of Death
Queensbury,NY Street Address 34 Willowbrook Road,Apt 303
n Natural Cause E Accident ❑Homicide El Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier
°1Name Title
Timothy Murphy,Coroner
Address
Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 14')
❑Burial Date Cemetery or Crematory
Ell Entombmer>t November 27,2017 Pine View Crematory
Address
®Cremation Quaker Road,Queensbury,NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
(95 ❑Transportation Shipment
p by Common Destination
Carrier
Li Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
z Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
'): Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
ei e i Remains are Shipped, If Other than Above
Address
17,1 Permission is hereby granted to dispose of the human re 'ns de. ' el a ve s ' icated.
Date Issued 11- D.1- aoii Registrar of Vital Statistics L,
(signs )
District Number 5657 Place Town of Queensbury,NY 12804
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z 5 Date of Disposition /l//
11 in Place of Disposition f.4,V J t' e4o--
(address)
co re (section) �„(lot
lot number (grave number)
pName of Sexton or Person in Charge of Premises q.st
uZ `', ( ease print)
Signature l/t Title ittlemirP(t
....,,4__.
(over)
DOH-1555(02/2004)