Misch, Michelle Christine NEW YORKSTATE DEPARTMENT OF HEALTH 3 icy
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michelle Christine Misch Female
Date of Death Age [fVetera n of U.S.Armed Forces,
03/28/2020 46 Years War or Dates
E.. Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
U Manner of Death Natural Cause Accident Homicide Suicide Undetermined Mir Pending
Circumstances Investigation
WW Medical Certifier Name Title
Michael Sikirica MD
Address
50 Broad Street,Waterford Town, New York 12188
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 156
Burial Date Cemetery,Crematory or Facility Name
04/07/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
OZ Removal Date rand/or
lace Removed
F, and/or Held
N Hold Address
O
I- Date Point of
N ❑Transportation
C! 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
f— Remains are Shipped,If Other than Above
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/07/2020 Registrar of Vital Statistics Wp&7,t,4 �rewCurtzr(EkrtronicalZyS0=4
(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:
t~—
W Date of Disposition Io Place of Disposition
P111
address)
W
N
(section) lot numberl (grave number)
Name of Sexton or Person in Charge of Pre ises CAr:, L A'41it
Z print)
rint/
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on r , 20
Pine View Cemetery Representing the'funeral home named on burial permit
Official Funeral Directors Reg.or License#
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