Thompson, Mildred NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mildred J Thompson Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/29/2015 81 years War or Dates
t:: P e of Death Hospital, Institution or
W City dfciitXX6'l'AGYM Glens Falls Street Address Park St Glens Falls, N Y
p ner of Death `� Natural Cause Accident Homicide El Suicide Undetermined 0 Pending
U �� Circumstances Investigation
al Medical Certifier Name Title
0 Rachid Daoui M D
Address
1 West Medical Suite 305 Saratoga Springs, NY
Death Certificate Filed District Number Register Number
it 17c)00 4-11 fatjf ( Glens Falls 5601 225
UBurial 'Date. • • . Cemetery or Crematory
04/30/2015 Pineview Crematory
❑Entombment Address .
[ 'Cremation Queensbury, N Y 12804
Date Place Removed
❑Removal and/or Held
and/or
Address
Cl) Hold
0 Date Point of •
0 Li Transportation Shipment • .
0 • by Common Destination
Carrier -
Disinterment Date Cemetery Address
❑Reinterment Date. Cemetery Address
iiIiiiPermit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
<> Address -
• P O Box 277 Fort Ann,'N Y 12827
Name of Funeral Firm Making Disposition or to Whom
1 . Remains are Shipped, If Other than Above
', Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/30/2015 Registrar of Vital Statistics O.30., G '
(si ature)
District Number 5601 Place Glens Falls .� /29i/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
kLI Date of Disposition -li i l,6' Place of Disposition , ,at . �',4rir.__
(address)
W
fil
l (section) r (lot number) (grave number)
Ci Name of Sexton or Person in Charge of Premises f 41
= L
r ,r� ( lease print)
t mi Signature Title47„401994
(over)
DOH-1555 (02/2004)