Thompson, Cory NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
'` Name First Middle Last Sex
, Co Michael Thompson Male
Date of Death Age If Veteran of U.S. Armed Forces,
r December 10, 2016 20 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
#-. ofUndetermined Pending
�" Manner Death ❑X Natural Cause Accident ['Homicide Suicide n n
Circumstances Investigation
< Medical Certifier Name Title
.. Timothy Murphy,Coroner
aZ
Address
AR Glens Falls,NY _ _
;: Death Certificate Filed District Number Register Number
J.
Y VillageGlens Falls, NY 5601 (6 /City, or
❑Burial Date Cemetery or Crematory
December 13, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
E' Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
el Name of Funeral Home Regan Denny Stafford Funeral Home 01443
i. Address
r 53 Quaker Road, Queensbury, NY 12804
- Name of Funeral Firm Making Disposition or to Whom
;` Remains are Shipped, If Other than Above
f Address
fH
Permission is hereby granted to dispose of the human remains described above as indicated.
.,' Date Issued t Z / / 3/16 Registrar of Vital Statistics L)c ve- \.A.)-A-is-c4
(signature)
71 District Number 5 6 0; Place 6 C .'V S ri,k\S,N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition j2/4//(p Place of Disposition pl-k e c.1 j-ems Cc 'ic�-icvy
W (address)
CO
0 (section) // (lot number) (grave number)
p0 Name of Sexton or Per n in Charge of Premises i,-1.- )r a K C.1ita.& Gh£
1Z (please print)
Signature Title 6 Ce Wei-id
(over)
DOH-1555(02/2004)