Burke, Thomas Allen Jr, NEW YORK STATE DEPARTMENT OF HEALTH ., Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas Allen Burke Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/29/2021 61 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 109 Bay Street,Glens Falls,New York 12801
• Manner of Death El Natural Cause 0 Accident Homicide ❑Suicide ❑ Undetermined Pending
W C.) Circumstances Investigation
CI James
Certifier Name Title
James Mcdonough PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 225
❑ Burial Date Cemetery,Crematory or Facility Name
06/02/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑ Donation
6 Removal Date Place Removed
and/or and/or Held
t- Hold Address
t/
0
a. Date Point of
(I) Li Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/01/2021 Registrar of Vital Statistics fXP5ertAndreu'Curtis g ctronica*Signea'
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition (p/71 1,1 Place of Disposition
2 (address
W
Cl) (section) ifint number) (grave number)
• Name of Sexton or Person in Charge of Premiss (A �- 5w�'t
(please lnt)
UJ
Signature Title (-My}r k
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014 c `w
Receipt
1 Human remains of delivered on , 20
1
IPine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#