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Dineen, Thomas Anthony NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas Anthony Dineen Male Date of Death Age If Veteran of U.S.Armed Forces, 03/26/2021 56 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village South Glens Falls Village Street Address 7 Jackson Avenue,South Glens Falls Village,New York 12803 ILI p Manner of Death © Natural Cause ❑Accident ❑Homicide 0 Suicide El Undetermined 0 Pending W Circumstances Investigation W Medical Certifier Name Title G Thomas Kandora MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village South Glens Falls Village 4524 9 ▪Burial Date Cemetery,Crematory or Facility Name 03/30/2021 Pine View Crematory Entombment Address O Cremation Queensbury Town,New York ▪Donation Z Removal Date Place Removed and/or and/or Held F- Hold Address N 0 Date Point of N 11 Transportation Shipment Q by Common Carrier Destination 'Date Cemetery Address 0 Disinterment Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 2 Address Cr W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/30/2021 Registrar of Vital Statistics Shannon Kelleher(Electronically Signed) (signature) District Number 4524 Place South Glens Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— /f Z Date of Disposition 31.3) IT' Place of Disposition Ott_ 'td,.._ W (address) W Q (section) / (iotnumber) (grave number) 8 Name of Sexton or Person in Charge of Premises ` tti L, ' r Z ease prZ /nt) • Signature Title 6 71"t rat DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0143bC Receipt Human remains of . - delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#