Coleman, Thomas I 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Tra sit Permit
Name Firstomas Middle oleman Sex
Date of Death Age If Veteran of U.S. Armed Forces,
01/03/2014 64 years War or Dates
i Place of Death Hospital, Institution or
X City, 14V6rXXl * Saratoga Springs Street Address Mary's Haven
W Manner of Death Natural Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
11 Patriciar Ford M. D.
AC d7/�awrence Street, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, TX X9rX) Saratoga Springs 4501 2
❑Burial Date Cemetery or Crematory
01/06/2014 Pine View Crematory
❑Entombment Address
®Cremation Queensbury N Y
Date Place Removed
Z❑Removal and/or Held
2 and/or
I. : Address
Cl) Hold
O Date - Point of
EL 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 Compassionate Funeral Care D0364
Address
402 Maple Ave., Saratoga Springs, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
W
Permission is hereby granted to dispose of the human remai rib ab ' dicate
Date Issued 01/06/2014 Registrar of Vital Statistics t
(signature)
District Number 4501 Place Saratoga Springs
�- I•certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z.
C
111 Date of Disposition I Aim Place of Disposition ei, v,,,/
(address)
UI
rE (section) , (1 t number '. (grave number)
▪ Name of Sexton or Persona Charge of Premises et //t(" ✓ utN ,it
please pant)
Signature C L- Title CieiVicart
(over)
DOH-1555 (02/2004)