Loading...
Needham, Thomas Clarence t- ' It fZs NEW YORK STATE DEPARTMENT OF HEALTH ��`"' Burial - Transit Permit 1 Bureau of Vital Records Name First Middle Last Sex Thomas Clarence Needham Male Date of Death Age If Veteran of U.S.Armed Forces, 11/28/2020 87 Years War or Dates 1953-1955 1.. Place of Death Hospital,Institution or WCity,Town or Village Chester Town Warren Street Address 128 White Schoolhouse Road,Chester Town Warren,New York 12817 p Manner of Death ©Natural Cause 0 Accident El Homicide 0 Suicide Undetermined 0 Pending ILI 0 Circumstances Investigation G Medical Certifier Name Title Douglas Dennett MD Address 101 Ridge Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Chestertown 5652 14 ElBurial Date Cemetery,Crematory or Facility Name 11/30/2020 Pine View Crematorium_ El Entombment Address Cremation Queensbury Hamlet,New York 0 Donation Removal Date Place Removed and/or and/or Held H Hold Address U) 0 IL Date Point of U) Li Transportation 5 by Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/30/2020 Registrar of Vital Statistics Mindy Conway(ECectronicaaySigned) (signature) District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition �Z ZO Place of Disposition Po P 1Eii 2 (address) W CC (section) (lot number) ' (grave number) 8 Name of Sexton or Person in Charge of Premises th ts.� L � . (YvI A4t1 z (plea print) q W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) �.�14 2 4 5 Receipt Human remains of delivered on - , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#