Thomas, Gregory If . ' 16 t1763
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex Gregory L. Thomas Male
_ _
'.,..;. Date of Death Age I If Veteran of U.S. Armed Forces,
3/19/2013 56 1 War or Dates No
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Place of Death ; Hospital, Institution or
Q . Town •4 0,-:Ict Stony Creek
; Street Address 204 States Rd.
Manner of Death 12s.n Natural Cause 0 Accident 0 Homicide 0 Suicide 1-1 Undetermined n Pending
Circumstances 'Investigation
Medical Certifier Name Title
'.* Eric Pillemer M.D.
Address
Glens Falls Hospital, Glens Falls,NY
Death Certificate Filed 1 DistrpNibm)?9:r ; Register Number
-..-:.;
TownMCNIKI ( Stony Creek : k IA.)
Date Cemetery or Crematory
1::Burial 1 3/22/2013 Pine View Crematory
- -
.. ; Address
;. LL3Cremation! Queensbury, NY
Date Place Removed
L___i r-i Removal
! and/or Held
and/or
Hold
0
1 Date ; Point of
]Transportation Shipment
7, by Common Destination
• Carrier
Date Cemetery Address
Ej Disinterment
Date : Cemetery Address
0 Reinterment .
;11-11 Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral itome, Inc. 00211
.:-.-.,
Address
24 Church St., Lake Luzerne,NY 12846
IF; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above; Address ,
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Permission is hereby granted to dispose of the human remains described, ve as indic ted.
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Date Issue ..3/,g./ ba 13 Registrar of Vital StatisticS- 24-OL.t_. s,il
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.,. : (signature)
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District Number05-8 Place
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.:.. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,.
;.-4. Date of Disposition 1-7 -13 Place of Disposition ?it/f41%) al*its-
-7; (address)
(section) A (lot number( (grave number)
•4' Name of Sexton or Person in Charge o Premises ente
lliig."
...4 (please print) f
,. ' Signature Title Cee_tr)ria,
DOH-1555 (10/89) p. 1 of 2 VS-61