Monahan, Thomas NEW YORK STATE DEPARTMENT OF HEALTH. ` 4 M
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas Joseph Monahan Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/07/2012 63 years War or Dates No
Place of Death Hospital, Institution or
Z City, ?Tow X7'illitYA Schenectady Street Address Ellis Hospital
Iiicf Manner of Death lOatural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
;n Medical Certifier Name Title
G Oteng Walebowa M D
Address
1101 Nott St, Schenectady, N Y 12308
ffi Death Certificate Filed District Number Register Number
City, Tow (xiiXX Schenectady 4601 622
i ❑Buri,al Date Cemetery or Crematory
07/10/2012 Pineview Crematory
❑E ombment Address
iM PI= emation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
❑and/or
� Address i;;
Hold
th
Date Point of
Cti
ta❑Transportation Shipment
G by Common Destination
gi Carrier
❑Disinterment Date Cemetery Address •
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00276
Address _
68 Main St, Box 67, Hudson Falls, N Y 12839
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;; Address
W.
''' Permission is hereby granted to dispose of the human remains des,ed Fboyei4ti is ed,
Date Issued 07/09/2012 Registrar of Vital Statistics U'U` # ",,.i`-is-ir"
(nature)
gp District Number 4601 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition -1 ill !1L Place of Disposition i,.,Uu.J CorryArri10-.,
2 (address)
w
Ca-
CC (section) (lot number) (grave number)
0
Name of Sexton or P rson in Charge of Premises >Jt ', e'••b"1'
z (please print)
41
Signature 4 _ "i— - Title Ce r66t,
(over)
DOH-1555 (02/2004)