Boule, Terrence E , . .„.. 37k
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Terrence E.Soule Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/15/2022 78 Years War or Dates 1964-68
Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death l Natural Cause Accident ElHomicide OSuicide Fpndetermined ❑Pending
Circumstances Investigation
8, Medical Certifier Name Title
Kasandra Frasier PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
Ci ,Town orViLtage i 5601 215
Burial Date Cemetery,Crematory or Facility Name
04/18/2022 Pineview Crematorium
Entombment Address
Cremation Queensbury Town,New York
❑Donation
IIRemoval Date Place Removed
and/or ur and/or Held
#" Hold Address
&�ElTransportation Date Point of
by Common Shipment
Carrier Destination
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
}• Remains are Shipped,If Other than Above
X Address
1r
iu
f Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/18/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
1 (signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition LI ii$j it Place of Disposition 'F.,...Lt/..-._ ` 0r._
111
II (address)
w
01
EC (section) (tot number) - (grave number)
)3 Name of Sexton or Person in Charge of Premises f"i ,J; 11t11,�
(pie print)
Ai
/1) ,
Signature Title L OMit
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of , delivered on , 20
Pine View Cemetery Representing the funeral home named:on bnrjal permit
Official Funeral Directors Reg.or License# 'f