Carlin, Michelle NEW YORK STATE DEPARTMENT OF HEALTH`
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michelle Kathrin Carlin Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/20/2017 43 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ri"—I Undetermined ❑Pending
Circumstances Investigation
€ Medical Certifier Name Title
Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 448
s❑Burial Date Cemetery or Crematory
08/23/2017 Pine View Crematory
['Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/23/2017 Registrar of Vital Statistics 4/p6ertACurtis ECectronical[ySigned"
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition g/18f nPlace of Disposition v6� (r-l*4,f or...
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ,.r
401
(p/eape u print)/
Signature Title G ik
_'
(over)
DOH-1555 (02/2004)