Wallace, Thomas W. Jr. L�
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NEW YORK STATE DEPARTMENT OF HEALTH
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas W.Wallace Jr. Male
Date of Death Age It Veteran of U.S.Armed Forces,
04/19/2022 70 Years War or Dates
Place of Death Hospital,Institution or
W City,down or Village Hudson Falls Village Street Address 264 Main Street 8•9,Hudson Falls Village,New York 12839
(, Manner of Death EI Natural Cause []Accident pi Homicide []Suicide []Undetermined []Pending
W Circumstances I 'Investigation
U
W Medical Certifier Name Title
Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,down or Village 5726 24
Burial Date Cemetery,Crematory or Facility Name
04/26/2022 Pine View Crematorium
[]Erltombntent Address
[]Cremation Queensbury Town,New York
[]Donation
flRemoval Date Place Removed
and/or and/or Held
Id Address
U?
0
EL Date Point of
t►1[]transportation
El by Conrrrron Shipment
Carrier Destination
Date Cemetery Address
ODisintennent
Date Cemetery Address
[]Reintennent
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 First Making Disposition or to Whom
Remains are Shipped,If Other than Above
5 Address
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/26/2022 Registrar of Vital Statistics Cyx11.4iyi Alain rElsctmn Sk/nx9
(aignalur el
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
C~ '
W 21 Date of Disposition q' f ZZ Place of Disposition r:✓ -
2 (od1,ess//
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N
(sekthu,/ (loth r;r (;rave number)
SName of Sexton or Person in Charge of Premises l (r `�'•A4`1
(N sep,inlJ
UJ Signature Z?, Title (�4-040-
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DOH-1555 l07/18)p 1 of 2 /
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#