Martinson, Thomas -7q1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas Martinson Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/20/2021 72 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death Natural Cause El Accident 1=1 Homicide Suicide Undetermined ID Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Marcille Labban MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 408
Burial Date Cemetery,Crematory or Facility Name
09/22/2021 Pine View Crematory
ElEntombment Address
gCremation Queensbury Town,New York
ElDonation
Z Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d. Date Point of
Cl) ❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
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
Remains are Shipped,If Other than Above
5 Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/21/2021 Registrar of Vital Statistics Rp6ert Andrew CurtirgkctronicaQSrgnet0
(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:
Z Date of Disposition 41 11Z('� Place of Disposition ''('"Inca..,
2 (address)
W
(section) (lot number)_5/4 (grave number)
0 Name of Sexton or Person in Charge of P mises 4(p e print)
(P ,t',
W Signature Title 4 tem
Wit
DOH-1555(07/18)p 1 of 2
• 1
01 166
Public Health Law Sec. 4145(2b)
Receipt
Human remains of - delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#