Stormer, Michael NEW YORK STATE DEPARTMENT OF HEALTH ir no
Vital Records Section , - Burial - Transit Permit
'' Name First Middle Last Sex
Michael Allen Stormer Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 4, 2017 52 War or Dates Air Force
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 8 Queen Ann Court
Manner of Death ❑X Natural Cause ❑Accident fliomicide ❑Suicide n Undetermined n Pending
04 Circumstances Investigation
* Medical Certifier Name Title
., John Sawyer M.D.
Address
,, ' 161 Carey Road, Queensbury,NY 12804
Death C iicate Filed Dist* Number Regi ter Number
Cit Town r Village �� (, (�,�
❑gu� Date Cemetery or Crematory
January 5, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ 1-1 Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
yTransportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reintern. Date Cemetery Address
` ; Permit Issued LL Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iLL
Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued ( I Irl i Registrar of Vital Statistics C C` , L.L.--.�
__ (signature)
District Numbe Place 1 o t�� V \ L,,�S,_
I certify that the remains of the decedent identified above were disposed of in acc rdance ith this permit on:
Z p Coyhci nrn....
Lu Date of Disposition I G Il Place of Disposition T� r.✓
(address)
W
N
re (section) (lot number) ( (grave number)
pName of Sexton or Person in Charge of Premises itrts'trlz, 314/tr($
Z (phase print)
W
Signature 6 Title (i c-InftPL
(over)
DOH-1555(02/2004)