Passaro, Thomas NEW YORK STATE DEPARTMENT OF HEALTH tt Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Thomas Hawley Passaro Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 21,2015 58 War or Dates
Place of Death Hospital, Institution-atoga Center For Rehab And Skilled
City, Town or Village Ballston Spa Street Address Nursing
tti
Manner of Death Undetermined Pending
X Natural Cause Accident Homicide Suicide
Circumstances Investigation
w Medical Certifier Name Title
a Stephen Stradel
Address
Ballston Spa,NY
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
III Entombment Address
23, 2015 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date I Place Removed
Z I I Removal j and/or Held
and/or Address
_I"' Hold
N
O Date I Point of
NI 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
.1..;1 Remains are Shipped, If Other than Above
N Address
A
`° Permission is her by granted to dispose of the hu an r ins des i above as indicated.
Date Issued 1 2. S Registrar of Vital Statis
/ �® (signature)
District NumbeL1Q Place v</rt7 GJ 1 2 t f 7 q ,'6L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 'MI fi S Place of Disposition 'gm V,,, er tpv
2 (address)
W
U)
Ce (section) (lot7iumber (grave number)
Q Name of Sexton or Person in Charge of Premises /4i4 neitt
'Z jjrrr� (Obese print)
Signature �f..� Title /1/E-O ,L
(over)
DOH-1555 (02/2004)