Wade, Thomas .a r II
NEW YORK STATE DEPARTMENT OF HEALTH 5�b
Vital Records Section Burial - Transit Permit
Y Name First Middle Last Sex
Thomas Neil Wade Male
- Date of Death Age If Veteran of U.S. Armed Forces,
August 12, 2015 69 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
f. Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
R} Circumstances Investigation
'.r Medical Certifier Name Title
,_ Joanne Cooper PA-C
�. Address
100 Park Street,Glens Falls,NY 12801
/ Death Certificate Filed District Number Register Number ^II
City, Town or Village Glens Falls, NY 5601 HQy
❑Burial Date Cemetery or Crematory
August 14, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iPermit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i. Permission is hereby;anted to dispose of the human emain describ d above,,icated.
.; Date Issued 0 1+ U� Registrar of Vital Statistics 02 '
A. (signature)
District Number 5-Zoe) / Place Glens Falls,NY
r_::1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition g/l6I(5- Place of Disposition ty If,.) C Apr,.,,
2 (address)
W
CO
O (section) //j/f(lot numper) (grave number)
O Name of Sexton or Person in Char a of Premises `(,,it- Ji g-
C 1�Z (p ase print)
W fhL,��
Signature6 Title j21t
(over)
DOH-1555(02/2004)