Willett, Thomas M NEW YORKSTATE DEPARTMENT OF HEALTH Burial-Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas M Willett Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/11/2021 62 Years War or Dates 1977-83
F., Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
pManner of Death Natural Cause Accident Homicide ❑Suicide El Undetermined ❑Pending
Circumstances Investigation
C.) Medical Certifier Name Title
CI Jozef Oweis
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Albany 0101 0735
ElBurial Date Cemetery,Crematory or Facility Name
03/13/2021 Pineview Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
El Donation
Z Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
u) ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
.`� Address
I
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/12/2021 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition l3-/3-.0.2 l Place of Disposition �u A) e J t ou CJ`_r'tti r-
(address)
W
OC
(section) (lot number). (grave number)
g Name of Sexton or Person in Ch of Premises
(please print)
W Signature 7• L Title e `c` - -r
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 0140 Z)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official funeral Directors Reg.or License#