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Choppa Michael ��gs NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael Choppa Male Date of Death Age If Veteran of U.S.Armed Forces, 02/29/2020 77 Years War or Dates F Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 53 1 Maple Drive Lane,Queensbury Town,New York 12804 'p Manner of Death © Natural Cause Accident Homicide Suicide g Undetermined Pendin C) Circumstances Investigation QW Medical Certifier Name Title Anne Evans DO Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town orViRage Queensbury 5657 33 Burial Date Cemetery,Crematory or Facility Name 03/03/2020 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation 0 Removal Date Place Removed H and/or and/or Held N Hold Address O to Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address 1EIReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/02/2020 Registrar of Vital Statistics CaroCine9fifdegarde Barber(ECectronicallySigned) /signature/ District Number 5657 Place Queensbury, 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 313170 Place of Disposition W 2 (address/ W CA /sedion/ /ot number/ (grave number/ Name of Sexton or Person in Charge of Premises r Z D /p/eas print/ W Signature .( ,�� Title r DO H-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of ' delivered on , 20 Pine View tnetery Represetiting the funeral'home named on burial permit Official Funeral Directors Reg.or License#