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Lindsey, Thomas NEW YORK STATE DEPARTMENT OF HEALTH ` ' s —AO Vital Records Section Burial - Transit Permit Name First Middle Last Sex Thomas Richard Lindsey Male Date of Death Age If Veteran of U.S. Armed Forces, 12 October 24, 2016 76 War or Dates Place o ath Hospital, Institution or w City, T wn r Village Moreau Street Address 162 Lamplighter Acres LI W` Manner o Death Natural Cause Accident Q Homicide Suicide 0 Undetermined El❑ Pending W Circumstances Investigation W Medical Certifier Name Title Ci Michael Adams MD, Address Moreau Family Health Ctr S. Glens Falls, NY Deat ificate Filed Di�tjic umber Regist N imber City Tow or Village h(l o r-� a �f 5 ❑Burial Date Cemetery or Crematory October 25, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed zriRemoval and/or Held • and/or Address F Hold N Date Point of IL ❑Transportation Shipment by Common Destination Carrier ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address 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 II_ Remains are Shipped, If Other than Above 2 Address W> Permission is hereby granted to dispose of the human remai describe b e as indicated. Date Issued /0 ,� pj(p Registrar of Vital Statistic (si nature) District Number 1/902__, Place/ PW/4/(16 /di //7 )6�"p 4.0 A '/)K • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W'' Date of Disposition 10/25/2016 Place of Disposition Quaker Road Queensbury,NY 12804 4 (address) W: (0 ✓ (section) (lot number)) (grave number) p• Name of Sexton or Person in Charge of Premises ��ns St�iilI �/ ( lease print) W- Signature �114- Title !r> (WPC, (over) DOH-1555 (02/2004)