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Ford, Thomas I
Town of Queensbury Certification of Cremation Pine View Cemetery and Crematory This certifies that the remains of: Thomas I Ford were cremated on April , 26 20 23 at the Pine View (Month) (Day) Crematorium, Queensbury, New York, and these are the cremated remains of said body. Date of Death April , 22 20 23 Age 85 (Month) (Day) Funeral Home Singleton,Sullivan,Potter Funeral Home Registered No. 376 (Authorized Signature) FORD NAME Thomas I Ford (1.... .....,.. Age: 85 Lot Owner: Thomas & Susan Ford Lot# Seneca 24 B Grave# 1 Case: Urn Died: 4.2 2.2 3 Interred: 5.2 0 .2 3 Funeral Home: Singleton Sullivan Potter Cemetery: Pine VIew NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thomas I Ford Male Date of Death Age If Veteran of U.S.Armed Forces, 04/22/2023 85 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 15 Overlook Drive,Queensbury Town, New York 12804 ILI 0 Manner of Death ❑^ Natural Cause ❑Accident Homicide Suicide Undetermined Pending W Circumstances Investigation EMedical Certifier Name Title Melanie Duerr NP Address 47 Tom Phelps Lane,Mineville Hamlet,New York 12996 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 66 Burial Date Cemetery,Crematory or Facility Name 04/25/2023 Pine View Crematory Entombment — Address ©Cremation Queensbury,New York ❑Donation 0 n Removal Date Place Removed F and/or and/or Held CO Hold Address 0 IL Date Point of (I)OTransportation la Common Shipment Carrier Destination Disinterment Date Cemetery Address OReinterment 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 � Remain s are Shipped,If Other than Above Address ill o' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/25/2023 Registrar of Vital Statistics Caroline x[cfegarde Barber(E(ectronicalTy Signed) (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: 1� W Date of Disposition 9)2 13 Place of Disposition 17.4V,_ Zl u s---... 2 (address) W Q (section) dy (lotpumber) (grave number) 8Name of Sexton or Person in Charge of Premises f, 1... 4It Zr (please print/ W Signature Title C�r�M�Tp�t DOH-1555(o7/18)p 1 of 2 t` , 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# FORD , THOMAS. .SUSAN 4.11f) Owner Thomas & Susan Ford Address Plot A 15 Overlook Dr. Oueensbury, NY 12804 �� . Phone # Lot # 518-796-6995 24B Deed # Date 4206 8/21 /2020 Cost Foundation Y - N si 9'n on Location North-Sherman/Lards South-Abbey East-Murphy West-Path Remarks I ACKNOWLEDGE THE RECEIr OF THE RULES AND REGULATIONS OF THE PINE VIEW CEME RY: SIGNATURE: - / DATE: I ' :0 '26W SIGNATURE: 5,__AAJOADLITL Ftt, DATE: iir` ' l°219 Record of Interments 1 , 44•9a3 6 s \ cx� • �• ac•a5 2 7 3 8 4 9 5 10 34 - z A / 2US x '\ A R. P W E >E 4.1 w 2 . .3 . a . � � � ET