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White, Michael Arthur NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael Arthur White Male Date of Death Age If Veteran of U.S.Armed Forces, 12/18/2019 66 Years War or Dates � . Place of Death Hospital,Institution or WCity,Town or Village Fort Ann Town Street Address 1431 County Route 17, Fort Ann Town,New York 12827 G Manner of Death ©Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation a ttf Medical Certifier Name Title 0 John Stoutenburg MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 5754 11 ❑Burial Date Cemetery,Crematory or Facility Name 12/20/2019 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation 0 ❑Removal Date Place Removed and/or and/or Held H tfi Hold Address Date Point of N ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above '$R Address W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/23/2019 Registrar of Vital Statistics Barbara I WWinchell(ECectronicaCCy Signer) (signature) District Number 5754 Place Fort Ann, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ` W Date of Disposition 1 Z-2/-�9 Place of Disposition W (address) W Ir (section) of number) / (grave number) Name of Sexton or Pers i C e f Premises - (&& Z (please print) BJ Signature Title DOH-1555(07/18)p f 2 Public Health Law Sec. 4145(2b) Receipt Human remains of %� delivered on ' , 20 P,i'ne View Cemetery Representing the funeral home named oq b 'al rmit Official Funeral Directors Reg.or License# 4( t.�