Stevens, Thomas NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section . ,,,
Name First Middle Last Sex
Thomas A. Stevens Male
Date of Death Age If Veteran of U.S. Armed Forces,
08 / 27 / 2015 92 War.or Dates N/A
}- Place of Death Hospital, Institution or
Z City, Town or Village Wilton Street Address 107 Cabin Dr.
0 Manner of Death®Natural Cause El Accident E Homicide E Suicide �Undetermined 0 Pending
Circumstances Investigation
tu Medical Certifier Name Title
0 Robert Nielson DR
Address
3044 NY-50, Saratoga Springs, NY 12866
nii Death Certificate Filed District Number _/ Register Number
iii§! City, Town or Village Wilton y5lie�
OBurial Date Cemetery or Crematory
S / / t',S--- Pine View Crematory
El Entombment Address /�,
<.z Z Cremation ( £ ..4. ,K , Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
>: Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
Address
tligi 402 Maple Ave. , Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
UI
Permission is hereby granted to dispose of the human remains described ab9q'ye as indicated.
z Date Issued S 28—2O 1SRegistrar of Vital Statistics -//�� / &
giiii �<` (siting
District Number Z'' Place Wilton , New York
I certify that the remains of the decedent identrfied above were disposed of in accordance with this permit on:
ui Date of Disposition ?d3(i0r Place of Disposition r..u� c ii-cut i........
(address)
ilk
11 (section) 4 (lot number) (grave number)
Q Name of Sexton or Person i.0 Char of Premises •. �'
Z please print) •
/ �.. •
Signature ("�`' Title
•
(over)
DOH-1555 (02/2004)