Jacobs, Thomas NEW YORK STATE DEPARTMENT OF HEALTH t - ) it R P-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas Jacobs Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 10, 2014 87 War or Dates WWII
II., Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 8 North Road
.p Manner of Death ❑X Natural Cause Accident ❑Homicide Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
AZ David Cunningham,MD
Address
3 Irongate Center, Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 /B 1
El Burial Date Cemetery or Crematory
❑Entombment April 11, 2014 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Iri I Removal and/or Held
and/or Address
f' Hold
U)
O Date Point of
V) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued `-I/ f/ //y Registrar of Vital Statistics tAJ" W
(signature
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:
Z c
W Date of Disposition �i Y'Iy Place of Disposition z tw tri-4 t—
W (address)
CL (section) ,-(lot number) (grave number)
pName of Sexton or Person in Charge of P emises 111R, StM'
Z yplease print)
W
Signature7 Title CP-roil Olt
(over)
DOH-1555(02/2004)