Lacombe Sr, Thomas l fi 377
NEW YORK STATE DEPARTMENT OF HEALTH~Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Y :: Thomas Lacombe,Sr. Male
'ir" Date of Death AgeIf Veteran of U.S. Armed Forces,
J:
May 2, 2015 88 War or Dates
,�'�ti.g Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death
X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
rr Roslyn Socolof Dr.
1
:: Address
::::42 Gurney Lane,Queensbury,NY 12804
g Death Certificate Filed District Number Register Number
;s:; City, Town or Village Queensbury 5657 ' 7 cf
❑Burial Date Cemetery or Crematory
May 4, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F Hold
0 Date Point of
Nn Transportation Shipment
p' by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;h:; Permit Issued to Registration Number
'i::i:� Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
:'i Address
407 Bay 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 r
'ns described abov s indicated.
Date Issuedl L{ �I C Registrar of Vital Statistics l`�`_
C.
: (signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 5/fills Place of Disposition 'elkilk/ erwi "s.
Ili
(address)
Cl)
IX (section) G h,, , (lot num (grave number)
GName of Sexton or Person in Charge of Premises ,� ell
Z ( lease print)
W Signature Gam• Title NC+r1.2
(over)
DOH-1555(02/2004)