Haley, Thomas Edward (4,1_,
(0
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Thomas Edward Haley Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/29/2022 87 Years War or Dates 1955-1957
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pending
G Natural Cause Accident Homicide Suicide
W Circumstances Investigation
W Medical Certifier Name Title
O Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 667
F Burial Date Cemetery,Crematory or Facility Name
01/03/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
O❑Removal Date Place Removed
and/or and/or Held
H
N Hold Address A
0
Date Point of
(A❑Transportation Shipment
Q by Common
Carrier Destination
DisintermentDate Cemetery Address
0 Reinterment
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
1— Remains are Shipped,If Other than Above
2 Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/03/2023 Registrar of Vital Statistics Megan.Norn(/ctronicaf Stgne./
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I- ----,i1
Z Date of Disposition )I t{/3 Place of Disposition ' L A-....„
111
(address)
W
N Q (section) (lot number) ( �� (grave number)
SName of Sexton or Person in Charge of P • / n l'n __, .- -,i/sAA
Z (plea print/
W Signature Title rgkr)A ar
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# y i i'`