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Seeley, Michael S7r NEW YORK STATE DEPARTMENT OF 4,IEALTf;Vital Records Section Burial - Transit Permit Name First Middle Last Sex Michael Edward Seeley Male Date of Death Age If Veteran of U.S. Armed Forces, August 17, 2016 49 War or Dates IPlace of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Deathiii Natural Cause ❑ Accident ElHomicide ❑ Suicide ❑ Undetermined El❑ Pending Investigation 0' W Medical Certifier Name Title 0 Nadarajah Balasubramanian, Address 1101 Nott St Schenectady, NY 12308 Death Certificate Filed District Number 1 Register Plumber City, Town or Village d ❑Burial Date Cemetery or Crematory August 22, 2016 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 • Date Place Removed z ❑ Removal and/or Held and/or Address p` Hold Pine View Crematorium Date Point of a ❑Transportation Shipment CO by Common Destination p' Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I_ Remains are Shipped, If Other than Above 2 Address W tl Permission is he eby granted to dispose of the human r ain escribed bove as ind' ated Date Issued 0/ Registrar of Vital Statistics -a--)� . �/`-_ G��-,1=�� ignature) District Number 56,6I Place ,..4 (` I certify that the remains of the decedent identified above were isposed of in ccorda ce with this permit on: Z /Ark.e�[ 4) 0r- w. Date of Disposition 08/2�' /2016 Place of Disposition Quaker Road Queensbury,NY 12804 Z`' (address) W 0) (section) // (Jot number) (grave number) ca Name of Sexton or rsonc; Charge of Premises `��^'�'w✓' (/�� �� W ,/� /J (Please print) Signature / � . /���"' Title G /'.en''.4A4-d /, (over) DOH-1555 (02/2004)