Bonomo, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
r..
Name First Middle Last Sex
$::: Thomas Bonomo Male
r Date of Death Age If Veteran of U.S. Armed Forces,
r
•g April 5, 2014 36 War or Dates
i:.: Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
pi
Circumstances Investigation
:.6 Medical Certifier Name Title
ti David Cunningham Dr.
Address
3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
___ City, Town or Village Glens Falls 5601 / 7 9
❑Burial Date Cemetery or Crematory
April 10, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
S. Address
lig
▪ Permission is hereby granted to dispose of the human remains desscc ibed boy as icated.
Date Issued O0p�1O/V Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition '111°Ii04 Place of Disposition ftktilf,4,4 Lo'-^'t0 r+.-...
2 (address)
W
CO
O (section) A (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises /60p.. 1 - Sitt,at
Z (p dase print)
W
Signature 4 �� Title C�r�CiMry'f012-
(over)
DOH-1555(02/2004)