Watson, Thomas H %/9
N EW YORK STATE DEPARTMENT OF HEALTH @Burial
Bureau of Vital Records - Transit Permit
Name First Middle Last Sex
Thomas H Watson Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/13/2023 65 Years War or Dates
__ Place of Death Hospital,Institution or
WCity,Town or Village Harrietstown Town Street Address Adirondack Medical Center-Saranac Lake Site
p Manner of Death ifi Natural Cause Accident Homicide Suicide (Undetermined ❑Pending
W Circumstances Investigation
tJ
G Medical Certifier Name Title
Ronald Keough Coroner
Address
40 Academy Street,Saranac Lake Village Franklin,New York 12983
Death Certificate Filed Town Of Harrietstown District Number Register Number
City,Town or Village 1663 82
Burial Date Cemetery,Crematory or Facility Name
"-' 11/17/2023 Pine View Crematory
Entombment
_ Address
®Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
d Date Point of
U)ETransportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Clark Inc 01075 01075
Address
2310 Saranac Ave,Lake Placid,New York 12946
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
j Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/17/2023 Registrar of Vital Statistics .Soerinalfanirorr(Electrontea(SrWirecf)
(signature/
District Number 1663 Place Town Of Harrietstown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WH // �
Date of Disposition /J ��az3 Place of Disposition 19 i tJL V,e.� C iv 44o,ft
W (address)
CO
It (section) (lot rum er/� (grave number)
gName of Sexton or Person in Charge f Premi es k'/4 Y/>i 40 do
el 0 1 (please print)
W Signature t — ` II' Title DPenc—Fot—
DOH-1555(07/18)pi of 2 G�
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#