Fuss, Thomas F 3s z
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas F. Fuss Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/22/2022 60 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
p Manner of Death El —(
Natural Cause Accident 0 Homicide Suicide FUndetermined Pending
I' I1Circumstances Investigation
W Medical Certifier Name Title
C George Siniapkin MD
Address
604 Palmer Avenue,Corinth Town,New York 12822
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 227
Burial Date Cemetery,Crematory or Facility Name
04/26/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
2 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/25/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(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:
Z Date of Disposition 11710I 72, Place of Disposition ?ailrel—s) �J c��11J
W
CC (section) /7(lot number (grave number)
lt
O Name of Sexton or Person in Charge of Pre 'ses (/ r! erint) ��
Z (P ` '�
W Si nature Title_Z
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#