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Thackrah, Benjamin NEW YORK STATE DEPARTMENT OF HEALT1 . 1 Vital Records Section Burial - Transit Permit % Name First Middle Last Sex fff Benjamin Thackrah Male .. Date of Death Age If Veteran of U.S. Armed Forces, el March 20, 2014 65 War or Dates Place of Death Hospital, Institution or 7 City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death r—li Xi Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Dean Reali,MD Address Glens Falls,NY 1 Death Certificate Filed District Number Register Numi?er ;�;.�, ,yam City, Town or Village Glens Falls,NY 5601 ❑Burial Date Cemetery or Crematory March 24,2014 Pine View Crematorium ❑Entombment Address ©Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed ZZ ri Removal and/or Held 2 and/or Address H Hold V) 0 Date Point of N0 Transportation Shipment 5 by Common Destination Carrier n Disinterment Date Cemetery Address n Reinterment Date Cemetery Address ' Permit Issued to Registration Number �" fj.J Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 f� Address .,Sr 407 Bay Road,Queensbury, NY 12804 `_; Name of Funeral Firm Making Disposition or to Whom 1 Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above i dicated. Date Issued 034/070"/ Registrar of Vital Statistics /44Y,a (signature) 5yj%j' `' District Number 5601 Place Glens Falls,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition �Jia�.II4 Place of Disposition TotLj Erc.,cidnu.— u (address) W CO O (section) Ll (ot number) (grave number) p Name of Sexton or Person i Charge of Premises Y'(� �r'n(61 Z please print) W Title �Er1M VtZ Signature -4--. (over) DOH-1555(02/2004)