Havens, Thomas NEW YORK STATE DEPARTMENT OF HEALTH b, t
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Thomas E. Havens Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 22,2012 75 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 59 Hickory Hill Rd.
Manner of Death I xi Natural Cause I 'Accident Homicide Suicide Undetermined n Pending
Circumstances Investigation
u. Medical Certifier Name Title
0 Gary Scidmore
Address
6930 State Rt.8,Brant Lake,NY 12815
Death Certificate Filed District Number Register Number
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
January 24,2012 Pine View Crematory
Entornbrnent Address
®Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O "and/or Address
I' Hold
O Date Point of
N j Transportation Shipment
by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00034
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
LI
.W
arL Permission is reb granted to dispose of the hu i escribed ove as indicated.
Date Issued Registrar of Vital tistic
(signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (- -12%2 Place of Disposition ,'yiev eW (fie w cr r- ru v✓1
(address)
W
U)
(section) (lot number) (grave number)
Op Name of Sexton or Person in Charge of Premises i rh o'11 l3ry n e 1(e
Z (please print)
W
Signature t Title ire -wi�r�( I�SS
(over)
DOH-1555(02/2004)