Wardell, Thomas LA(52,,
DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Thomas Wardell Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/29/2015 58 years War or Dates
Place of Death Hospital, Institution or
Z City, dGii T X*SOWN( Glens Falls Street Address Glens Falls Hospital
Ct Manner of Death Natural Cause Accident ❑Homicide 0 Suicide 0 Undetermined Pending
1 Circumstances Investigation
W Medical Certifier Name Title
G Wendy Stennacker PAC
• Ad1lr0e0sHark St Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, TOW&MO Glens Falls 5601 273
❑Burial Date Cemetery or Crematory
06/01/2015 Pine View Crematorium
❑Entombment Address
QCremation Queensbury, NY 12804 •
Date Place Removed
Z El❑Removal and/or Held
W. and/or Address
M= Hold
Cl)
O Date Point of
Pii Q Transportation Shipment
Gs by Common Destination
Carrier
Q Disinterment Date Cemetery Address •
Q Reinterment Date Cemetery Address
p.iPermit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01821
Address
11 Alqonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
IE Remains are Shipped, If Other than Above
,'; Address
Ir
W
"` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/01/2015 Registrar of Vital Statistics k.Aj k 'l,N
(signa���
District Number 5601 Place Glens Falls i N
IH I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition a(j((c Place of Disposition gmU..- t -• --'
(address)
(section) ,(lot num r) (grave number)
r
Name of Sexton or Person in Charge of Premises .` 3,..'
ignature41 (please print)Title `a,i
(over)
•
55 (02/2004)