Franzen, Michael r aVINEW YORK STATE DEPARTMENT OF HEALTH/ -
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael Allen Franzen Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 22, 2018 60 _ War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 79 Warren St Apt 104
Manner of Death n Natural Cause 0 Accident El Homicide 0 Suicide riUndetermined Eln Pending
tit
Circumstances Investigation
Ur Medical Certifier Name Title
Ageel Gillanni,
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
_t_") City, Town or Village 5601 L...i i 1
A.,...,-®Burial Date Cemetery or Crematory
August 25, 2018 St. Paul's Cemetery
0 Entombment Address
D Cremation Vaughn Road Kingsbu
Date I Place Removed
,0"A.A1 Removal and/or Held
' and/or Address
Hold St. Paul's Cemetery
c Date ,nt of
Transportation 1 Thipment
by Common Destination
n Carrier
0 Disinterment Date Cemetery Address
yr
Reinterment Date Cemetery Address
Permit Issued to Registration Number
s
A. Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
t Name of Funeral Firm Making Disposition or to Whom
;Fa Remains are Shipped, If Other than Above
Address
€,,e Permission is hereby granted to dispose of the human remains described above as indicated.
dr-
4 Date Issued q) 2? / ?-o I$r Registrar of Vital Statistics � �,�j , �_'v� ^i— .,
(signature
District Number 5601 Place 6 CQA,..S cfn\\S _U� i
lz
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/25/2018 Place of Disposition Vaughn Road Kingsbury,NY 12839
(address)
I
(lot number) (grave number)
Name of Sexton or Person in Charge of Premises / �, � 5
Z (please print)
W Signature Title (I*"
(over)
DOH-1555 (02/2004)