Earley, Michael Hugh �b
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records w
Name First Middle w Last Sex
Michael Hugh Earley Male
Date of Death Age If Veteran of'(J.S.Armed Forces,
03/31/2020 74 Years War or Dates 1965-1971
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 89 W Notre Dame Street, Glens Falls, New York 12801
'p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Laurie Dennison NP
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 153
Burial Date Cemetery,Crematory or Facility Name
04/02/2020 Pine View Crematory
Entombment Address
517 Cremation Queensbury Town, New York
Donation
0 Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
a. Date Point of
N �Transportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
(.. Remains are Shipped,If Other than Above
Z Address
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/02/2020 Registrar of Vital Statistics Tp&tt,4)wre-Curtu(E§ctronwa1Ty Sagne4
(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:
~ L �
Z Date of Disposition 111170 Place of Disposition
W (address)
2
W
N (section) (lot numbed (grave number)
� 910�4—Name of Sexton or Person in Charge of Pr ises
/ease prin Z
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013 Eel,J0
Receipt
Human remains of !; _ °_ delivered on T , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# '
i