Guido, Michael NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
r Name First Middle Last Sex
Michael Guido,Dr. Male
Y Date of Death Age If Veteran of U.S. Armed Forces,
October 7,2015 47 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 28 So. Western Ave
r Manner of Death Natural Cause Accident Homicide n Suicide Undetermined Pending
Circumstances Investigation
..• Medical Certifier Name Title
'' Timothy Murphy
Address
52 Haviland Ave,Glens Falls,NY 12801
A Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 1 l P I
❑X Burial Date Cemetery or Crematory
❑Entombment October 10, 2015 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z
I I Removal and/or Held
and/or Address
t•- Hold
U)
0 Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 BayRoad, Queensbury,NY 12804
,r Name of Funeral Firm Making Disposition or to Whom
I.:
Remains are Shipped, If Other than Above
Address
.,;� Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10—`1- a O 1 Registrar of Vital Statistics 42 ` Qn-21--- m-k-j`4`k,--
(signature)
District Number 5`, ` -7 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ili g Date of Disposition 1 0/1 0/1 5 Place of Disposition Pine View Cemetery, Queensbury, NY
(address)
N Erie 10C 1
re
(section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises Connie L. Goedert
Z -' \gon (please print)
W Signature, /t4..`.Q -2 0(....e._ / Title Cemetery Superintendent
(over)
DOH-1555(02/2004)