Squires, Michael NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
gig Name First Middle Last I Sex
Michael Squires male
Date of Death Age If Veteran of U.S. Armed Forces,
: 12/02/1998 21 mo_. War or Dates n/a
E Place of Death Hospital, Institution or
3 CityXXMIX( Glens Falls Street Address 45 McDonald Street
Manner of Death JJ Natural Cause Li Accident 0 Homicide 0 Suicide El Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
Mary J. Nevins, MD
liii Address
84 Broad Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
CityaMMXIMIUX Glens Falls 5601 S 9 9
Date Cemetery or Crematory
Burial 12/04/1998 Pine View Cemetery
Address
El
- ----Cremation
• Quaker Road, Queensbury, NY 12801
Date Place Removed
0❑Removal and/or Held
c; aHoldnd/or Address
0
Q Date Point of
y ❑Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address .
Permit Issued to Registration Number
>= Name of Funeral Home Regan & Denny Funeral Home 01565
Address
53 Quaker Road, Queensbury, NY 12801
''''' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
L
ft
tiii Permission is hereby granted to dispose of the human remains describeddescri,ec. bolA cc.s i c *ed.
Date Issued IzI y/cB' Registrar of Vital Statistics X
(signature)
Mii
i District Number 56e / Place 6 L.ai�•..s ce,\�S , fy'q
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
WDate of Disposition 12/4/98 Place of Disposition Pine View Cemetery , Queensbury , NY
2 (address)
U3 Huron 20-B 1
CC (section) (lot number) (grave number)
AName of Sexton or Person in Charge of Premises Rodney G M n s h R r
z (please print)
r4 Signatur ,.� Title Superintendent
(over)
DOH-1555 (9/98)