Tobin, Ernest w )
NEW YORK STATE DEPARTMENT OF HEALTH . If 71 D
Vital Records Section Burial - Transit Permit
Name irst Middle ,Last . ( Sex
,QA/� 5r ,J- fl t3 / O I&I" N Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 2, 2016 94 yrs. War or Dates 1940 - 1945
Place of Death Town of Hospital, Institution or The Stanton Nursing
ii City, Town or Village Queensbury Street Address & Rehabilitation Center
0 Manner of Death Natural Cause Accident 0 Homicide 0 Suicide 0 Undetermined Pending
ILI Circumstances Investigation
W Medical Certifier Name Title
1:::1 Joanne Cooper PA
Address
152 Sherman Ave. , Glens Falls, New York 12801
Death Certificate Filed Town of District Number Register Number
City, Town or Village Queensbury S 1451 1Lt-2•-
❑Burial Date Cemetery or Crematory
11 /04/2016 Pine View Crematory
El Entombment Address
®Cremation Queensbury, TIP York
Date Place Removed
Z Removal and/or Held
R and/or Address
- Hold
0 Date Point of
Al 0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
nii Address
11 Algonkin St. , Ticonderoga, New York 12883
ig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
Lu
B Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1- 5-ao I to Registrar of Vital Statistics --204.A. -A,.,..� A_ �
(signature)
District Number %51 Place WU e�n S bvl
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ILI Date of Disposition 1l I n, Place of Disposition ,rN04�., C }ri_►
2 (address) t
11
ta
CC (section) r. (lot number) (grave number)
ci Name of Sexton or Person in Charge of Pr mises `�r. tin 11
(pl se print)
-1 Signature { , Title ogkivArliX
(over)
DOH-1555 (02/2004)