Lopez, Michael NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael Lopez Male
Date of Death Age j If Veteran of U.S. Armed Forces,
September 25, 2011 52 War or Dates
Place of DeathI Hospital, Institution or
Z. City, Town or Village Glens Falls ; Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
tii Circumstances Investigation
Hi Medical Certifier Name Title
a Dr Eric Pillemer,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601
❑X Burial Date Cemetery or Crematory
September 30, 2011 Mt Herman Cemetery
❑Entombment Address
❑Cremation Queensbury, NY 12804
Date Place Removed
Z [ !Removal ! and/or Held
O and/or Address
H Hold
N i
O Date Point of
co Transportation Shipment
p 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 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i. Remains are Shipped, If Other than Above
:2 Address
:tea
Permission is hereby granted to dispose of the human remains described above,as indicated.
Date Issued q /2V/, Registrar of Vital Statistics W7eA4--1.4? tnl-A(signal e)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 9/30/11 Place of Disposition Mt. Herman Cemetery
(address)
CO Family Plot
(se i n) (lot number) (grave number)
0p Name of Sexton or Person in Charge of Premises Michael Genier
W (please print)
Signature" 9j �. Title Superintendent
(over)
DOH-1555(02/2004)