Stimpson, Thomas William 1L1�
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas William Stimpson Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/28/2022 71 Years War or Dates 1973-1975
f. Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 35 Bluebird Road,Moreau Town, New York 12803
W Manner of Death Undetermined Pending
W
V Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
0 Tanya Finch NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 32
HBurial Date Cemetery,Crematory or Facility Name
06/01/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
DDonation
Date Place Removed
Removal and/or Held
H and/or
N
Hold Address
0
Date Point of
CO Transportation Shipment
p by Common —
Carrier Destination
Date Cemetery Address
Disinterment
El Reinterment
Date Cemetery Address
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 Firm Making Disposition or to Whom
i.— Remains are Shipped,If Other than Above
a Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/01/2022 Registrar of Vital Statistics Leeann Mc ca6e(ECectronica(!ySigned)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l—
Z Date of Disposition 1,12 I it Place of Disposition �LU
% ....., �"�
address)
N (section) /1`allot number) (grave number)
EC ///9
8 Name of Sexton or Person in Char of Premises (pl se print)
z C{ '"4(
W Signature .�� Title
DOH-1555(07/18)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,bwial permit
Official Funeral Directors Reg.or License#