VanGundy, Thomas R � YOGI
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas R.VanGundy
Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/02/2022 71 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
j+ Manner of Death IDNaturalCause ❑Accident 0Homicide Suicide Undetermined ❑Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
a Melody Long PA
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
Cit ,Town or VillageE 5601 512
Burial Date Cemetery,Crematory or Facility Name
Addre2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Don atio n
cl❑Removal Date Place Removed
and/or and/or Held
F Hold Address
0
a. Date Point of
U) Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
EjReinterment
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
I— Remains are Shipped,If Otherthan Above
S Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/07/2022 Registrar of Vital Statistics Negate 9roan ifElextrotrica6Signtrl)
(signature)
District Number 5601 Place City Of Glens Fails
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition JQ-g`ZO2z V i (u Place of Disposition P t,ew e(�['ry�1�c.t'D �
2 (address) ��
W
Cl)et (section) (lot tuber) (grave number/
SName of Sexton or Person in Charg of Pre .ses // 10,E 1 J £�r7A
Z ]� (please print)
W '
Signature Title 0610-44L
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#