Hewitt, Thomas NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Thomas R. Hewitt Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. February 10, 2014 88 War or Dates WW li
Z Place of Death Hospital, Institution or
W City,Town,or Village Johnstown Street Address Fulton Center Rehabiliation
G Manner of Death 17I Natural Cause 0 Accident 0 Homicide EISuicide Undetermined El Pending
W Circumstances Investigation
() Medical Certifier Name / Title
W �4'o/26 �a 2 n1;176 L i' '�0
0 _ Address _
F Lc-;=ry cib d Od2-1 >aQV-e(x) /�,7- Af- / :S' v/3 ,
Death Certificate Filed District Number Register Number
City,Town or Village Johnstown Hs,/ e
❑Burial Date Febua ' 13, 2014 Cemetery or Crematory
� Pineview Crematorium
❑Entombment Address
El
Cremation Quaker Road Queensbury New York 12887
2 Date Place Removed
0 Ei Removal and/or Held
- and/or Address
I' Hold
0 Date Point of
0 0 Transportation Shipment
Q by Common Destination
i Carrier
Date Cemetery Address
6 0Disinterment
El Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jilison Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
X• Remains are Shipped, If Other than Above
Ui Address
G.
Permission is hereby granted to dispose of the human remains des i above as/Odic .
Date Issued 0,9104a0 I7 Registrar of Vital Statistics /�
(sig ure)
District Number /'7 Sy Place Johnstown,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 3(id IN Place of Disposition ' a uM! Ce..c/lorw
W (address)
ai
(section
)) (lo um r) � (grave number)
ZName of Sexton or Person in harge of Pre ises r,t � 1n,+lt
W (please print)
Signature /(rt._
Title fEp1t}
(over)
DOH-1555 (02/2004)