LaMarque, Thomas Howard (1........_. ...,:)
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas Howard LaMarque Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/29/2022 83 Years War or Dates Army
.,_ Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
a Manner of Death ❑X Natural Cause Accident Homicide Suicide FlUndetermined Pending
11.11
U Circumstances Investigation
WG Medical Certifier Name Title
Came Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 57
Burial Date Cemetery,Crematory or Facility Name
08/02/2022 Pine View Crematory
Entombment— Address
IiCremation Queensbury,New York
EiDonation
Z Removal Date Place Removed
and/or and/or Held
t Hold Address
N
Transportation Date Point of
ZS by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
CIReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
}, Remains are Shipped,If Other than Above
X Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/02/2022 Registrar of Vital Statistics Aimee L Wa/wney(Electronicaly Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition g'2(7Z Place of Disposition ' 'vtL 44...
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(address)
W
ii (section/ � (lot member) (grave number)
O Name of Sexton or Person in Char Premises r (.r 11 I
Z (pe se print/
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Signature Title L f �I
DOH-1555(07/18)p 1 of 2
I
Public Health Law Sec. 4145(2b)
Receipt Ai At
I
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#