Kylioe, Michele r S
# g5,
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
N• ame First Middle Last Sex
Michele Irene K Hoe Female
D• ate of Death Age If Veteran of U.S. Armed Forces,
06/21/2017 58 Years War or Dates
Place of Death Hospital, Institution or
of, City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death❑ ❑ ❑ ❑ ❑Undetermined ❑Pending
•3_ X Natural Cause Accident Homicide Suicide
Circumstances Investigation
M• edical Certifier Name Title
Nawed Siddiqui MD
tv
Address
Ei 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
Cit , Town or Village Glens Falls 5601 345
-❑Burial Date Cemetery or Crematory
06/23/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
--7 ❑Removal
and/or Held
44, and/or Address
; Hold
va Date Point of
• ❑Transportation Shipment
by Common Destination
RI Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
IX Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
r/ 3809 Main St,Warrensburg,New York 12885
,... Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
is
• Address
Permission is hereby granted to dispose of the human remains described above as indicated.
re-
Date Issued 06/23/2017 Registrar of Vital Statistics ,6e,tAcurt;s ECectronicaItySigned
(signature)
FR District Number 5601 Place Glens Falls, New York
nit I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
j Date of Disposition (0/it/117 Place of Disposition ni ll-..1 (mow}
(address)
(section) /'/(lot number) d (grave number)
Name of Sexton or Person in Charge f Premises L h*a L J+yn€t4
m /, (ple se print)
I t Title L
Signature C
(over)
DOH-1555 (02/2004)