Golden, Tommy NEW YORK STATE DEPARTMENT OF HEALTH 62
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tommy Robert Golden Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 12, 2015 66 War or Dates
Place of Death Hospital, Institution orrif`' City, Town or Village Glens Falls Street Address Glens Falls Hospital
et Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
ur Medical Certifier Name Title
3 Elizabeth Hutchins, ANP-C,
Address
2 Broad Street Queensbury, NY 12804
Death Certificate Filed District Number Register Nu b r
City, Town or Village 5601 c_5"-
70 Burial Date Cemetery or Crematory
November 18, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
t❑ Removal and/or Held
• and/or Address
., Hold
- Date Point of
❑Transportation Shipment
cazi by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
a; Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
-_ Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
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 re ains de ribed abo as indica -d.
" Date Issued //%/640/ef Registrar of Vital Statistics i;1(2-4�-) ' l o'9 -C
4 (signature)
District Number 5601 Place 7 ,zs,Wls, / /.RV
1...1'4
I certify that the remains of the decedent identified above were •isposed of in accordance with this permit on:
LLi Date of Disposition 11/18/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2. (address)
W
C1?
(section) / (lot number)` (grave number)
0' Name of Sexton or Person in Charge of remises hr,r 3tiwt-
A ( ase pent) �,�J
tE: Signature Title tig-
(over)
DOH-1555 (02/2004)