McLaughlin, Michael 1 U NEW YORK STATE DEPARTMENT OF HEALTH qc9
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Michael Scott McLaughlin Male
Date of Death Age If Veteran of U.S. Armed Forces,
f August 4,2017 61 War or Dates Vietnam
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 2587 Route 9L
Manner of Death Q Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Christopher Mason,MD
` Address
Glens Falls,NY
1 Death Certificate Filed District Number Rpgjs��ter,.[Vumber
City, Town or Village Queensbury, NY 5601 �U
❑Burial Date Cemetery or Crematory
August 7,2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ['Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Date Cemetery Address
❑Reinterment
n Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
,., Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains describedri- a^bc v(ee as indicated.
Date Issued ) lo1C�1� Registrar of Vital Statistics �, �—�
(..a''
(signature)
District Numbe (A�� Place l a �s- -,-� �-j_
I certify that the remains of the decedent identified above were disposed of in a rdanc ith this permit on:
Z pp
w Date of Disposition S/1 I fl Place of Disposition +,m tkw alot---
2 (address)
W
co
tY (section) //(lot number) (grave number)
OName of Sexton or Person in Charge of Premises ibr�s - r ..Si-4n
Z (plus print)
W Signature c Title 1 J+jtTt
(over)
DOH-1555(02/2004)