Seeley, Thomas l07 3--
NEW YORK STATE DEPARTMENT OF HEALTH t 1
Vital Records Section Burial - Transit Permit
Name First • Middle Last Sex
Thomas M Seeley Male
Date of Death Age If Veteran of U.S. Armed Forces,
04f/27/2014 81 years War or Dates
P of Death Hospital, Institution or
City owr)(p( ill�(g�()()( Glens Falls Street Address Park St Glens Falls, N Y
13 r of DeathNatural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
ill Circumstances Investigation
tu Medical Certifier Name Title
41 Agee!A. Gillani M D
Address
102 Park Street Glens Falls, N Y 12801
Certificate Filed District Number Register Number
,City, ow00004ll (X( Glens Falls 5601 207
Burial Date Cemetery or Crematory
❑Entombment 04/29/2014 Pineview Cemetery
Address
emation . Queensbury, N Y
Date Place Removed
Z Removal and/or Held
9 �and/or
Hold Address
to
O - Date Point of
in Li Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
111
fl` Permission is hereby granted to dispose of the human remains described above as,indicated.
Date Issued 04/28/2014 Registrar of Vital Statistics L&) Cif Z V Al
(signature)
District Number 5601 Place Glens Falls i 1/V / -&?//
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition Hint(c� Place of Disposition �;�„c,•O _J C'^�#oc>vu
1 (address)
tti
to
CC (section) * (lot number) (grave number)
B f.
Name of Sexton or Pe on in Char a of Premises Gh6 '` �t44(
Z ( se print)
• Signature L!'/it L. Title 0304"Kli_
g
(over)
DOH-1555 (02/2004)