Helms, Thomas John (..t...
NEW YORK STATE DEPARTMENT OF HEALTH �
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Thomas John Helms Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/23/2022 76 Years War or Dates 1965-1969
H Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
LLJ
Manner of Death ZNatural CauseAccident 1:11Homicide Suicide Undetermined ❑Pending
CI Circumstances Investigation
W I Medical Certifier Name Title
W Donald Tessitore NP
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 1439
Burial Date Cemetery,Crematory or Facility Name
06/24/2022 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
O. Date Point of
to❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30,Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
IIC
Ui
CI. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/24/2022 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:Z Date of Disposition (o J jy 1 Z1 Place of Disposition I- 4-r�1
t„
W
2 (address)
W �� _
CC N (section) I (lot number) e��V11 (grave number)
ill
caName of Sexton or Person in Charge 'ses �'
ease print)
Z �^
W Signature �� Title `t'-cif T�
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#