Mangiacasale, Thomas Jr. ,
-4 ZSZ
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas Mangiacasale Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/17/2022 67 Years War or Dates
I— Place of Death Hospital,Institution or
City,Town or Village Granvipe Town Street Address Haynes House of Hope
O
Manner of Death El Accident Homicide Suicide Undetermined ❑Pending
VCircumstances Investigation
LU Medical Certifier Name Title
CI John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Granville District Number Register Number
Cit E,Town orVilla�e 5756 15
Burial Date Cemetery,Crematory or Facility Name
03/211
2022 Pine View Crematory
Entombment Address
['Cremation Queensbury Town,New York
Donation
cl Removal Date Place Removed
p and/or and/or Held
N Hold Address
0
IL Date Point of
CO❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
DReinterment
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
I— Remains are Shipped,If Otherthan Above
"S Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/21/2022 Registrarof Vital Statistics itIfnyLtndrM Marta;(rEGetronicaQj,4714
(signature/
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this rniton:
Date of Disposition 317t I Z2 Place of Disposition _ "AV— 4ry
Iii
2 (address)
uJ
cc N (section) % (lot numbed (grave number)
SName of Sexton or Person in Charge of Pr mises t,Ti.. , ,sit
Zlease print)
IIISignature xy
Title `iNAIitTvie
DOH 1555(07/18)p 1 of 2
W F.
Public Health Law Sec. 4145(2b)
Receipt
1 Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#