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Piano, Thomas G gL 3 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit ~ * "' � Name First Middle Last Sex Thomas G Piano Male Date of Death Age If Veteran of U.S.Armed Forces, 10/11/2021 63 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause ❑Accident ❑Homicide 0 Suicide 0 Undetermined 0 Pending GW Circumstances Investigation Medical Certifier Name Title Farhana Kemal MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 451 ▪Burial Date Cemetery,Crematory or Facility Name 10/14/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York ❑Donation ElRemoval Date Place Removed p and/or and/or Held Hold Address U) ❑Transportation Date Point of a by Common Shipment - - Carrier Destination Disinterment Date 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 Remains are Shipped,If Other than Above Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/14/2021 Registrar of Vital Statistics RpbertAndrew Curtis(Efectronicaffy Signed) (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 W Date of Disposition 49 Place of Disposition Abe v,�e � eT,c„mQ�,�f/ (address) W N (C (section) (lot number) (grave number) gName of Sexton or Pe n in harge of Premises L., d+M G-414,2 (...-4.e (please print) W Signature Title C✓L, a 7 D e- DOH-1555(07/18) 1 of 2 r1152311 Public Health Law Sec. 4145(215)-• Receipt 1 Human remains of , ' , delivered on , 20 a: t , Pine View Cemetery Representing the funeral home named on burial permit f Official Funeral Directors Reg.or License# ' `