James, Thomas i 11_, /7
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thomas M.James Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/02/2018 86 Years War or Dates Vietnam
0-4
• Place of Death Hospital, Institution or
City, Town or Village Plattsburgh Street Address Champlain Valley Physicians Hospital Medical Ctr
Manner of Death 0 Natural Cause El Accident Ei Homicide 0 Suicide Undetermined El Pending
11,1
Circumstances Investigation
rei Medical Certifier Name Title
Cheryl Eustaquio MD
rm Address
ho
75 Beekman St,Plattsburgh,New York 12901
el Death Certificate Filed District Number Register Number
lei City, Town or Village Plattsburgh 0901 , 170
❑Burial Date Cemetery or Crematory
04/04/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or Address
Ilii Hold
Date Point of
1,79 El Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Fr-
Reinterment Date Cemetery Address
Li-
Permit Issued to Registration Number
Ft Name of Funeral Home Wilcox&Regan 01821
44 Address
• 11 Algonkin St,Ticonderoga,New York 12883
Name of Funeral Firm Making Disposition or to Whom
Lill Remains are Shipped, If Other than Above
Address
g
A Permission is hereby granted to dispose of the human remains described above as indicated.
1144 Date Issued 04/04/2018 Registrar of Vital Statistics Sylvia g cParrotte(LCectronicaCCySigned)
WI (signature)
District Number 0901 Place Plattsburgh, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Yri• l Date of Disposition LI /6-II c-ig Place of Disposition , U.� 404-
- (address)
(section) (lot number) (grave number)
44
Name of Sexton or Person in Charge of Premises ^ f
ease print)
riil
Signature & J-D- Title (004 'L
(over)
DOH-1555 (02/2004)