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Thomson, Cleon Andrew 111 ,--„ 41 z.-7-0 NEW YORK STATE DEPARTMENT OF HEALTH 0„. ...,F} Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Cleon Andrew Thomson III Male Date of Death Age If Veteran of U.S.Armed Forces, 03/16/2024 69 Years War or Dates F. Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address 58 Mason Street,Glens Falls,New York 12801 tp Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title G Charles Yun 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 155 F Burial Date Cemetery,Crematory or Facility Name 03/18/2024 Pine View Crematory Entombment _ Address ©Cremation Queensbury,New York Donation p n Removal Date Place Removed and/or and/or Held to Hold Address NTransportation Date Point of b by Common Shipment Carrier Destination Date Cemetery Address Disinterment ElReinterment 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 l- Remains are Shipped,If Other than Above 2 Address Q W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/18/2024 Registrar of Vital Statistics Megan No(in(Electronically Signed) (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— WDate of Disposition 1119 ill Place of Disposition t �ttt/:6� 6���^i�}�t i.v, 2 (address) W CO (section) // (lot number) (grave number) 8 Name of Sexton or Person in Charge of?remises <� l �fi z K/ (please print) / W Signature — '�— Title ` rf MA TM DOH-1555(07/18)p 1 of 2 3z I' ,< 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#