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Lumbis, Thomas F NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas F Lumbis Male Date of Death Age If Veteran of U.S.Armed Forces, 10/28/2021 67 Years War or Dates 1972-1973 Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Town Street Address 114 Hadlock Pond Road, Fort Ann Town, New York 12827 Manner of Death ©Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑Pending Circumstances Investigation tJJ Medical Certifier Name Title 0 John Aiken Coroner Address 40 Burquist Road,Fort Ann Town,New York 12827 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 5754 11 ElBurial Date Cemetery,Crematory or Facility Name 11/01/2021 Pine View Crematorium El Entombment Address lCremation Queensbury Town,New York ❑Donation (S Removal Date Place Removed and/or and/or Held - Hold Address 0 d Date Point of U) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 2 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/01/2021 Registrar of Vital Statistics Barbara 5 Winched('ECectronicalTySigned) (signature) District Number 5754 Place Fort Ann, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 11.1 �� L Z Date of Disposition �]�s Place of Disposition 2 (address) W CC (section) (lot number) (grave number) g Name of Sexton or Person in Charge of Premises S��^^%v'�'� (pi se print) W Signature Title �" t��- DOH-1555(07/18)p 1 of 2 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#