Dawson, Thomas L NEW YORK STATE DEPARTMENT OF HEALTH ail
# 3(,1/4.3
Bureau of Vital Records Burial - Transit Permit
of
Name First Middle
Thomas L.Dawson Last Sex
Date of Death Male
A Age If Veteran of U.S.Armed Forces,
4 04/27/2022 71 Years
igWar or Dates
Place of Death Hospital,Institution or
W
City,Town or Village Glens Falls Street Address 43 Ridge Street 704,Glens Falls,New York 12801
p Manner of Death
W X Natural Cause nAccident iiii Homicide ESuicide 1---Ices Undetermined ❑Pending
Circumstan
WCI
Medical Certifier Name Investigation
Alida King Title
NP
Address
v, 9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number
City,Town or Village 5601 Register Number
:, 238
-, Burial Date Cemetery,Crematory or Facility Name —
04/30/2022 Pine View Crematory
x Entombment
,; Address
Fat JCremation Queensbury Town,New York
,, Donation
ElRemoval Date Place Removed
. and/or and/or Held
- Hold Address
IX Date
CO❑Transportation Point of
by Common Shipment
ii Carrier Destination
tA
Date Cemete Address
.(_❑Disinterment ry
'l 0 Reinterment Date Cemetery Address
,.a
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
Ct
LU
G' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/29/2022 Registrar of Vital Statistics MeganWolin(ECectronicalrySigned)
44
(signature)
`T 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:
t- 1
tv
Date of Disposition i1Q'7Z Place of Disposition �4.... ,
W 1 ,(address)
N
tr (section) .(lot number) (grave number)
0 Name of Sexton or Person in Charge of ises ////// !,l(.. ,h,�
Wse print/
Signature ??
Title [!�1'�
DOH-1555(o7/t8)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 burial permit
Official Funeral Directors Reg.or License#