Thombs Sr., Richard E —)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard E.Thombs Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/17/2021 89 Years War or Dates
F— Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 39 Longview Drive,Queensbury Town, New York 12804
O Manner of Death ❑X Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
✓ Circumstances Investigation
Q Medical Certifier Name Title
Danushan Sooriabalan MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 194
ElBurial Date Cemetery,Crematory or Facility Name
09/20/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
pand/or and/or Held
N
Hold Address
ar t'r
N LiTransportatiofi Date Point of
fa Common Shipment
Carrier Destination
Disinterment
Date 'j1`' Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
N Address
CC
1!
4 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/20/2021 Registrar of Vital Statistics Caroline 9fli gari Bar6er(!YectronicaLySigned)
(signature)
District Number 5657 Place Queensbury, 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 1? Z Place of Dispositiond,,�
w (address)
W
N (section) (lot umber) (grave number)
it
0 Name of Sexton or Person in Charge of Pr s w �- �'
Z (please nt) /�
W Signature Title l( +"NW_
DOH-1555(07/18)p 1 of 2
015158
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named onburiaLpermit
Official Funeral Directors Reg.or License#