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Delsole, Michael Francis # 13� NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vita[Records Name First Middle Last Sex Michael Francis Delsole Male Date of Death Age If Veteran of U.S.Armed Forces, 02/10/2020 73 Years War or Dates F Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined Pending U Circumstances Investigation O Medical Certifier Name Title Gwendolyn Morris-Dickinson PA Address 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 69 Burial Date Cemetery,Crematory or Facility Name 0 2/1 112 020 Pine View Crematory Entombment Address nCremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held rn F— Hold Address O A. Date Point of W Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above Address W (L Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/10/2020 Registrar of Vital Statistics X96ertAndrew Curtis(6CectronicaCCySiynec) (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 I Z 1-to Place of Disposition LLI (address) W N (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premise Z (p ase print) W Signature L/ Title DO H-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) Receipt I Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#