Jones, Thomas P V NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas P.Jones V Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/18/2022 34 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Lake George Town Street Address State Route 9,Lake George Town, New York 12845
W Manner of Death
� 111 Natural Cause IllAccident �Homicide ESuicide FlUndetermined F.—pending
0
W Circumstances Investigation
W Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Lake George District Number Register Number
City,Town or Village 5651 17
Burial Date Cemetery,Crematory or Facility Name
08/29/2022 Pine View Cemetery
Entombment Address
nCremation Queensbury Town,New York
riDonation
o Date Place Removed
El Removal and/or Held
H and/or
Hold Address
0
d Date Point of
(I)LTransportation Shipment
p by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
n Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
2 Address
CC
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/22/2022 Registrar of Vital Statistics Patricia cR Mc-(Kinney-Schuster(Electronically Signed)
(signature)
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this C permit on: �1
Z Date of Disposition s. F.aa Place of Disposition a1 ( LtG e RA Y f(e_r_ni5 bej di icy
11.1
(address)
W ; n ///
N LC (section) �rbt number) (grave number)
0 Name of Sexton or Person in Charge of Premises i -tC..)C Cr--1-
Z (please print)
W Signature ; Title f l
DOH-1555(018)p t of 2
Public Health Law Sec. 4145(2b)
delivered 90 12934
Receipt
/
_.
HUman remains-9f i , ,,(,, ' rt':: V/ L - i -4°' , 20-• 1
n...-- , - i —'-
,
/ . .
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# • ,"
!
JONES
NAME Thomas P Jones V Age: 34
Lot Ownc brraine A Bowen
Lot# Mohican 29 E Grave# 1
Case: Concrete
Died: 8. 1 8.2 2 Interred: 8.2 9.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine View
-BOREN Two()
Lot No. 29
Address RD 1 Box 227 Hudson Falls, NY 12839 Section No. E
Owner Lorraine A. Bowen Plot Mohican
Date 11/12/91
Approx . 67 Superficial ft. @
Location Bounded on North by Bowen South by Vacant , East by Vacant ,
West by Robelen.
Corner Posts
Remarks
Deed No. (and changes) 2391
Payment Record Paid in Full 11/12/91
Record of Interments &t.3461
--: r)i)16.5 k 5 V 8 • c2a
2Xi THOMAS JONES IV 8/8/06 Y e
4 I C 5-71
5 A
7I
8 I Vic __
Form No. 01