Tomlinson, Willilam , .4 I 2
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William D. Tomlinson Male
Date of Death Age If Veteran of U.S. Armed Forces,
, January 9,2016 69 War or Dates
= Place of Death Hospital, Institution or
:Z: City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
Address
Two Broad Street,Glens Falls,NY 12801
v Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
January 12,2016 Pine View Crematory
❑Entombment Address
❑X Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
coTransportation Shipment
a by Common Destination
Carrier
I I Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
{2: Address
ce
W:
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ) Ill 1 6 Registrar of Vital Statistics W(7�. U )
(signav
District Number 5(20 ( Place 6<c2Jti\ S \\ 5 10 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition j/p;/((, Place of Disposition gult. C'O,, r0.,
W (address)
U)
re (section) 4 _(lot numbe (grave number)
pName of Sexton or Person in Charg of Premises Rr tar
Z (please print)
W Signature 4 Title ationI47 L
(over)
DOH-1555 (02/2004)