Regan, Michael F. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael F.Regan Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/16/2019 161 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Wens
of Death
W Natural Cause Accident Homicide Suicide Undetermined ❑Pending
V Circumstances Investigation
0 Medical Certifier Name Title
Stephen Perazzelli MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 539
❑Burial Date Cemetery,Crematory or Facility Name
12/18/2019 Pine View Crematory
Entombment Address
RiCremation Queensbury Town,New York
Donation
OZ Removal Date Place Removed
and/or and/or Held
N V) Hold Address
O
a Date Point of
N F1 Transportation
p by Common Shipment
Carrier Destination
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 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
Address
its
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/17/2019 Registrar of Vital Statistics Wp6ert., rrewC rtu(ElectronicaffyS4,n d)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 2 1 9 Place of Disposition i>LTV;c�J �2t'I'1G� z1/
W
2 /ad ress/
W
N (section) ` (lot number) (grave number)
C of Sexton or Pe on i har of Premises — J�ate4A4,e--4e-
Name � //pi asenZ W Cl �, —eSignature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) Q 13-1-6 0
Receipt
Human remains of E delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#