Tomlinson, Donald James '�
NEW YORK STATE DEPARTMENT OF HEALTH / f� Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald James Tomlinson Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/10/2023 64 Years War or Dates
ZPlace of Death Hospital,Institution or
City,Town or Village Queensbury Town Street Address 16 Kenwood Circle,Queensbury Town,New York 12804
pManner of Death E1 Natural Cause ❑Accident Homicide Suicide Undetermined Pending
VCircumstances Investigation
WO Medical Certifier Name Title
W Day PA
Address
79 North Street,Granville Town,New York 12832
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 5
Burial Date Cemetery,Crematory or Facility Name
01/11/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
O. Date Point of
M Transportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
OReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
a Address
Cr
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/11/2023 Registrar of Vital Statistics Caroline 1{i11egarce Barber(EfectronicaCCySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1/17123 Place of Disposition
2 (address)
W
(section) (lot number) (grave number)
g .
Name of Sexton or Person in Charge of Premises
Z (plelase print) /�
W Signature Title ` m�
DOH-1555(07/18)p 1 of 2
C 1659U
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#