Bollendorf, Michael ' # 70
NEW YORK STATE DEPARTMENT OF HEALTH `'
Vital Records Section Burial - Transit Permit
_; ; Name First Middle Last Sex
Michael W. Bollendorf Male
fa Date of Death Age If Veteran of U.S. Armed Forces,
March 9,2018 75 War or Dates
F Place of Death Hospital, Institution or
Z: City, Town or Village Warrensburg Street Address 21 Dinu Drive
f Manner of Death X Natural Cause n Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
tie Medical Certifier Name Title
CI Robert French PA
Address
Two Broad Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register lumber
y• City, Town or Village Warrensburg 5660 ,5
❑Burial Date Cemetery or Crematory
❑Entombment March 9,2018 Pine View Crematory
Address
iii Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
• ', Permit Issued to Registration Number
' Name of Funeral Home Alexander-Baker Funeral Home 00037
,;' Address
3809 Main Street,Warrensburg,NY 12885
-: Name of Funeral Firm Making Disposition or to Whom
_- ' Remains are Shipped, If Other than Above
21 Address
IX,
at
itl:
Permission is hereby granted to dispose of the human re int described above as indicated.
' Date Issued 03-09-2018 Registrar of Vital S:&tiatic, p;_k_ . C 7(S>
(signature)
District Number ,s9Ae0 Place l 0,,`,-,,\ o c- C-1/k.S6 Cl-r-'
I certify that the remains of the decedent identified above were disposed of in accordancec with this permit on:
W Date of Disposition 3)jtj►g Place of Disposition �'._J— 4-t�,
2 (address)
W
co
w (section) /(lot numb ) (grave number)
pName of Sexton or Person in Charge of Premises �t..,
LZ ? (pase print)
Signature / �' Title ly hall
(over)
DOH-1555 (02/2004)