Willsey, Michele NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section - Transit Permit
Name First Middle Last Sex
Michele Anne Willsey Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 15, 2018 48 War or Dates
}-- Place of Death Hospital, Institution or
wCity, Town or Village Moreau Street Address 3 C Skylark
w Manner of DeathL.
Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined n Pending
Circumstances Investigation
8 Medical Certifier Name Title
Robert P Reeves, Dr.
Address
Three Irongate Center Glens Falls, NY 12801
Death Certificate Filed Distric rrpbe Regist ,Number
City, Town or Village Moreau `�(� �/(P
0 Burial Date Cemetery or Crematory
May 21, 2018 Pine View Cemetery
0 Entombment Address
❑Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z 0 Removal and/or Held
and/or Address
Hold
Date Point of
CI
El Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date ' Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
2. Address
at
UJ`
0. Permission ish reb granted to dispose of the human r • escribed v s indicated.
Date Issued-1 11 )61? Registrar f V'al Statistics V b��
)
District Number pDPlacek-4d(Dt a it/4/CU / (s! natu
fk--/C_
6 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
us` Date of Disposition 05/21/2018 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
Iii1 Uncas # 1126 #22 5
t (section) (lot number) (grave number)
Name of S on or Person i Charge of Premises Connie Gr c1ert
.' f (please print)
"I Signatur e•3th" .4- Title Cemetery Suppri ntenrt.Pnt
(over)
DOH-1555(02/2004)