Waite, Thomas NEW YORK STATE DEPARTMENT OF HEALTH Y 1 � 2�
Vital Records Section
Burial - Transit Pe wit
Name First Middle Last Sex
Thomas Richard Waite , Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 30, 2011 39 War or Dates US Air Force
Place of Death Hospital, Institution or
: City, Town or Village Village of Lake George Street Address Shore Of Lake George
cf. Manner of Death Natural Cause I XI Accident I I Homicide Suicide Undetermined I I Pending
i3, 'Circumstances Investigation
g. Medical Certifier Name Title
FI; Timothy Murphy,Coroner
Address
Glens Falls,NY
- Death Certificate Filed District Number l� 2 V Register Number
City, Town or Village Village of Lake George
❑Burial Date Cemetery or Crematory
June 6, 2011 Pine View Crematory
❑Entombment Address
Cremation Quaker Road, Queensbury,NY 12801
Date Place Removed
Z Removal and/or Held
and/or Address
f' Hold
N
O Date I Point of
NI I Transportation Shipment
p by Common Destination
Carrier
I-1 Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
_:'? Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01464
:::: Address
53 Quaker Road, Queensbury,NY 12804
�'�'. Name of Funeral Firm Making Disposition or to Whom
` ; Remains are Shipped, If Other than Above
. Address
re
lit
,• Permission is hereb granted to dispose of the human re ains described above a i dicated.
q Date Issued 1,/ 2 I ) Registrar of Vital Statistics ,L..l�:1, 1. ../�'(
(signature)
aj District Number 5 6 2_0 Place Village of Lake George,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition (a 1 d rl( Place of Disposition p.„r - .%) 6..d.r..,N
i
2 (address)
COLU
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L (lot numbs 4j (grave number)
k
p (section)• Name of Sexton or Person in Charge of P miser c,step t J Q ANir
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11.1
Signature Title C2e t14 i)n--
,, (over)
DOH-1555(02/2004)