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Boisvenue, Sr. Thomas f N 41 gt,( NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit ::e:; Name First Middle Last Sex Thomas B. Boisvenue,Sr. Male Date of Death Age If Veteran of U.S. Armed Forces, September 15,2012 55 War or Dates Yes Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address 47 Gregwood Cl. ci Manner of Death U Natural Cause n Accident Homicide ❑Suicide Undetermined Pending IS Circumstances Investigation ul Medical Certifier Name Title O Timothy Murphy Coroner Address 52 Haviland Ave.,Glens Falls,NY 12801 ?r: Death Certificate Filed District Number Register���1Number City, Town or Village Queensbury 5657 I El Burial Date Cemetery or Crematory ❑Entombment Pine View Crematorium Address ©Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold W 0 Date Point of NTransportation Shipment a by Common Destination _ Carrier n Disinterment Date Cemetery Address ❑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 L++ Remains are Shipped, If Other than Above E, Address 5 Permission is hereby granted to dispose of the human re ains described abov as indicted. ,._. Date Issued I j Registrar of Vital Statistics (?�,� (signature) .: District Number 5657 Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z DispositionJ j Place of Disposition g4,0t0.4CW Date of � � �L p t�'art, W (address) N Ce (section) /J (lot number) (grave number) pName of Sexton or Person in Charge f Premises41 b/'�td W (please print) Signature Title Cqc-AIWTOIt (over) DOH-1555(02/2004)