Rehm, Michael NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section t Burial - Transit Permit
Name First Middle Last Sex
Michael P. Rehm Male
Date of Death Age If Veteran of U.S.Armed Forces,
1, July 15, 2016 17 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Clemons Street Address State Route 22
o Manner of Death El Natural Cause X❑ Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Michael Sikirica MD
0 Address
Albany New york
Death Certificate Filed District Number Register Number
City,Town or Village Clemons
❑Burial DateJuly 25,2016 Cemetery or Crematory
Pineview Crematorium
❑Entombment Address
❑X Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 iii Removal and/or Held
and/or Address
I' Hold
a
0 Date Point of
0 0 Transportation Shipment
ii by Common Destination
Carrier
- Date Cemetery Address
oDisinterment
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
CL
W Address
li
Permission is hereby granted to dispose of the human remains described above asindicated.
lit. i i
Date Issued 7-22-ZQ I� Registrar of Vital Statistics /..�
(signature)
District Number 57 52_. Place Clemons,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition '., zcilL Place of Disposition Pineview Crematorium
2 (address)
III
(h
0 (section) (ol..number) (grave number)
O Name of Sexton or Person in Charge of Premises (�/"ji pc St44,
Z (pl se print)
III
Signature .4 Title �hV,(
(over)
DOH-1555 (02/2004)