Mead, Michael { 40-9 #11Z
NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section 4 Burial - Transit Permit
Name First
�. Middle Last Sex
Michael William Mead Male
Y Date of Death Age If Veteran of U.S. Armed Forces,
` 5/25/2018 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 7 Morgan Ave
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Timothy Murphy,Coroner
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
:j-1 City, Town or Village Glens Falls,NY 5601 Zp 5
❑Burial Date Cemetery or Crematory
El Entombment Address
30, 2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
,' Name of Funeral Firm Making Disposition or to Whom
4 Remains are Shipped, If Other than Above
Address
Permission is h reby granted to dispose of the hu ,an remains described above as i led.
Date Issued / ' Registrar of Vital Stajstics Z / .- 44, A .'
,___e_:Sr
yi'gnature)
District Number `� Place
/I-
I certify that the remains of the decedent identified above were disposed of in accordan a with this permit on:
IF-
Z �
W Date of Disposition L/i 1 I Q Place of Disposition j+p»�� i, r�.
W (address)
CO
IX (section) f h (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises n� �t. -.)---i"
Z (Tease print)
In
Signature L mil d Title tir.t.idZit
(over)
DOH-1555(02/2004)