Thomas, David . II W 76,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
•f Name First Middle Last Sex
• ; David Franklyn Thomas Male
•j' Date of Death Age If Veteran of U.S. Armed Forces,
October 18, 2015 66 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death v‘iNatural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
? Medical Certifier Name Title
gi IA) HI cm 8o ,(c60j
Address Lfl
Ce.i.j Qssi , ,� ,Death Certificate Filed District Nueer jv I Register Number
.rr 5 6o 1 g 5 13
• r City, Town or Village
❑Burial Date Cemetery or Crematory
October 22, 2015 Pine View Crematorium
❑Entombment
Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
•r' 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
i.:, Date Issued fQ( i 1S Registrar of Vital Statistics (..P3C k
(signet e)
.:::: District Number 5 bo ‘ Place t giv`S V0. `"\s 1J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition M i ti/f Place of Disposition ,R,,,i, t.../ t`r ro.-.
2 (address)
W
U)
O (section) j�, (lot number (grave number)
C
O Name of Sexton or Person in Char a of Premises Gh�Z� a/4-
Z (p ease print)
W Signature / Title ( Ntt�'ia,/
(over)
DOH-1555(02/2004)