Cherubini, Michael Sr 1
NEW YORK STATE DEPARTMENT OF HEALTH ,- P SS
Vital Records Section Burial - Transit Perini t
Name First Middle Last Sex
Michael F. Cherubini Male
' Date of Death Age If Veteran of U.S. Armed Forces,
Jul i 4 , 2018 71 yrs. War or Dates 1968 - 1972
1- Place of Death Town of Hospital, Institution or
• City, Town or Village Hague Street Address 1 38 West Hague Road
a Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Ti"--1 Pending
ILI CircumstancesInvestigation
u Medical Certifier Name Title
Li Kathleen P. Huestis M.D.
Address
102 Race Track Road, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Hague 5653 3
❑Burial Date Cemetery or Crematory
07/09/2018 Pine View Crematory
['Entombment Address
;:;:;Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
1-1 and/or Address
M: Hold
CP
0 Date Point of
07 Li Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'; Address
cr
lu
41` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7/6/2018 Registrar of Vital Statistics ,, ,/-
(signature)
• District Number 5653 Place Town of Hagu7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ta Date of Disposition -)1 it l ig Place of Disposition g,,,LI� Comy,,,.,
(address)
ill
CA
CC (section) (lotnumber) c (grave number)
O Name of Sexton or Person in Charge of Premises /// ra L Enit
2: (please nt)
its Signature Title ll
(over)
DOH-1555 (02/2004)