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Callahan, Thomas NEW YORK STATE DEPARTMENT OF HEALTH " * Vital Records Section Burial - Transit Permit Name First Middle Last Sex Thomas Callahan Male Date of Death Age If Veteran of U.S. Armed Forces, r? -- September 27,2013 80 War or Dates Place of Death Hospital, Institution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined n Pending W Circumstances Investigation W Medical Certifier Name Title G Timothy Murphy Address 52 Haviland Ave,Glens Falls,NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 L.) t 1 ❑Burial Date Cemetery or Crematory El Entombment October 1,2013 Pine View Crematory Address ©Cremation Quaker Road, Queeensbury,NY 12804 Date Place Removed ZO ❑Removal and/or Held and/or Address H Hold N O Date Point of y ❑Transportation Shipment a 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 I Remains are Shipped, If Other than Above 2 Address OC W • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 3 if 3 d//3 Registrar of Vital Statistics W (signature) District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with t this permit on: Lu w Date of Disposition 16//31,) Place of Disposition (address) W N (section) (lot number] - (grave number) 0• Name of Sexton or Person in Charge f Premises �ii„ 30 Z "fiL (please print) W Signature Title CQ4S (over) DOH-1555(02/2004)