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Remsen, Thomas I. 3gI NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Thomas Richard Remsen Male Date of Death Age If Veteran of U.S. Armed Forces, May 21, 2016 31 War or Dates IPlace of Death Hospital, Institution or W` City, Town or Village Glens Falls Street Address Glens Falls Hospital CI Manner of Death �Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending W` Circumstances Investigation U W Medical Certifier Name Title a Aqeel A. Gillani, M.D. Dr. Address 102 Park St Glens Falls, NY 12801 th Certificate Filed gDistrict Number Register Number it , Town or Village i f n S iC, //S 5601 2 65 ❑Burial Date Cemetery or Crematory May 23, 2016 St. Paul's Cemetery El Entombment Address uuuuu ©Cremation Vaughn Road Kingsbury,NY 12839 Date Place Removed ❑ Removal and/or Held and/or Address F. Hold St. Paul's Cemetery Date Point of ❑Transportation Shipment CO by Common Destination 0 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above Address W a..' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 5 /2 3) )6 Registrar of Vital Statistics l/•-2 e ..0A). M4 (signature) District Number 5601 Place (o lS F-Gt I Is, N V I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I—' W Date of Disposition 05/23/2016 Place of Disposition Vaughn Road Kingsbury,NY 12839 2 (address) W. CO re (section) 4(lgt number) (grave number) 0, Name of Sexton or Person in Char e of Premises �firt_ ,S - Z (please print) W, Signature Title NV)it (over) DOH-1555 (02/2004)