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McInnis, Michael 34 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Michael James McInnis Male Date of Death Age If Veteran of U.S.Armed Forces, 01/06/2018 66 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause 0 Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Suzanne Rayeski DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number g. r,. City, Town or Village Glens Falls 5601 11 OBurial Date Cemetery or Crematory 01/09/2018 Pine View Crematory ❑Entombment Address = Cremation Queensbury Town, New York ol Date Place Removed ❑Removal and/or Held and/or Address (° a Hold Date Point of Q Transportation Shipment by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment 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 L Remains are Shipped, If Other than Above Address e'y I Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/09/2018 Registrar of Vital Statistics R,,bertf Curtis(E(ectronical(ySigned) (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: [ . Date of Disposition ( /f o f p g Place of Disposition `C' .t (address) n (section) lot number (grave number) Name of Sexton or Person in Charge of Pre ises -)3-•5t (p se print) 14 Signature Title MEMO/C.- (over) DOH-1555 (02/2004)