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Thomas, Marcia A
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Marcia A.Thomas Female Date of Death Age If Veteran of U.S.Armed Forces, 06/18/2021 68 Years War or Dates a_ Place of Death Hospital,Institution or Z City,Town or Village Hadley Town Street Address 91 2nd Avenue, Hadley Town, New York 12835 (3 Manner of Death ©Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑Pending W C.) Circumstances Investigation W Medical Certifier Name Title Kyle Leonard MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 12 ▪Burial Date Cemetery,Crematory or Facility Name 06/19/2021 Pine View Crematory ❑Entombment Address i▪ Cremation Queensbury Town, New York ❑Donation • Removal Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of N ❑Transportation by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 5 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/18/2021 Registrar of Vital Statistics Pauline G Smead(Electronically Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I-Z Date of Disposition 9o24. ( Place of Disposition 1 Q fC Aukhriy r--{ 2 (addr s W CC 0 (section) �1,/ (lot number) (grave number) �i f 0 a d 1�� L2cc.cl • Name of Sexton or Person in Ch e of Premis (please print) Z W Signature ` / Title o pex-.- DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) ' 1 4 8 7; Receipt Human remains of; delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#