Loading...
Corney, Michael NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Michael Warren Corney Male Date of Death Age If Veteran of U.S. Armed Forces, October 3, 2017 55 War or Dates } Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 110 Sagamore Street Apt 5c 0 Manner of Death Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending Circumstances Investigation W Medical Certifier Name Title O Darci Gaiotti-Grubbs, Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village 5601 `5 ❑Burial Date Cemetery or Crematory 1 October 5, 2017 Pine View Crematorium _T ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold In Date Point of • ❑Transportation Shipment tt) by Common Destination O Carrier Date Cemetery Address ❑ Disinterment ,7;❑ Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom J Remains are Shipped, If Other than Above " Address Ct IL Permission is hereby ranted to dispose of the human rains des ibed abo e as indica d. M Date Issued J 0 0 ' f Registrar of Vital St tistics /d1., ' v /✓ ' _ // (signature) District Number 5601 Place �„� 0_ =-ems ,7 ,, , I certify that the remains of the decedent identified above were • osed of in accordance ith this permit on: w Date of Disposition 10/0812017 Place of Disposition Quaker Road Queensbury,NY 12804 ;, ' (address) W' rk (section) (lot umber) (grave number) j Name of Sexton P so in Charge of Premises L.....I`�'�� G44'Z et G � Z (please print) W' Signature Title Cry (over) DOH-1555 (02/2004)