Thomson, Robert NEW YORK STATE DEPARTMENT OF HEALTH 1
" 8
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert S. Thomson j Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 10, 2012 47 War or Dates No
Place of Death I Hospital, Institution or
:Z City, Town or Village Lake George i Street Address 39 Platt Rd
:0. Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
l Circumstances Investigation
O. Medical Certifier Name / � � Title
Address / S
Death Certificate Filed ,District Number _ Register Nu ber
City, Town or Village Town Of Lake George 514` I
❑Burial Date Cemetery or Crematory
November 13, 2012 Pine View Crematorium
❑Entombment Address
Ii 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
N 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
t4 Remains are Shipped, If Other than Above
5; Address
u
Permission is hereby granted to dispose of the h 'ns described above assii dicated.
T_____
=. Date Issued 1 t t 3 / Registrar of Vital Statistics _ C . '`�
(signature)
`', District Number,h (Q V( Place Town Of Lake George
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Dispositiont Place of Disposition ,,aV /r04:7r,,1i,.;
W Date of alit'I ��1 L P pwJ (.'.
W (address)
U)
0 (section) (lot number) (grave number)
pName of Sexton or Person in Char a of Premises ��r,,J+- SB"44
Z ((please print)
W
Signature 4L Title /'(LE ii)f t V.,
(over)
DOH-1555(02/2004)