Lawrence, Thomas It
NEW YORK STATE DEPARTMENT OF HEALTH �S,
Vital Records Section f . % Burial - Transit Permit
Name First Middle Last Sex
Thomas Joseph Lawrence Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/05/2012 60 War or Dates No
Place of Death Hospital, Institution or
Z City, Town or Village City of Troy Street Address Seton Health/St. Mary's Hospital
a Manner of Death❑Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined Pending
UA Circumstances Investigation
ill Medical Certifier Name Title
q. Michael Sikirica, MD
Address
50 Broad Street Waterford, NY 12188
Vi Death Certificate Filed District Number Register Number
City, Town or Village City of TRoy 4102 1 j ,
['Burial Date Cemetery or Crematory
02/08/2012 Pine View Crematorioum
giil❑Entombment Address
Vii2Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
O❑and/or
Address
Hold
O Date Point of
Q Transportation Shipment
Q by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
68 Main Street Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
i4 Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued a14la Registrar of Vital Statistics
/(�� ���� (signature)
g. District Number I e ' Place `V�l,i '�
v i ficj
:? I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition -Fe to 1 t 10(' Place of Disposition =',,,�OWL./ Ct r�'antw...
Lu (address)
tO
te (section) (lot number
1 )(� (grave number)
i> Name of Sexton or Pe son in Charg f Premises nt"Tf a�t�+�r{�
(please print)
Ut SignatureTitle C7lr v 11 T. 1((L
Apk.-
(over)
DOH-1555 (02/2004)