Radcliff, Michael 20if
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name First Middle Last Sex
Michael G. Radcliff Male
4= Date of Death Age If Veteran of U.S. Armed Forces,
March 14,2016 68 War or Dates Vietnam
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
• ll Medical Certifier Name Title
P
Address
Death Certificate Filed District Number Register Number
City, Town or Village C/O Glens Falls 5601 1 y I
❑Burial Date Cemetery or Crematory
March 16,2016 Pine View Crematory
DEntombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
-' Permit Issued to Registration Number
_ Name of Funeral Home Alexander-Baker Funeral Home 00037
u Address
3809 Main Street,Warrensburg,NY 12885
'a Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
le
la
• Permission is hereby granted to dispose of the human remains described above as indicated.
j 6
Date Issued 3f 16 11 Registrar of Vital Statistics -i' 'vf . '
(signature)
District Number 5601 Place CIO Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3)18 ill, Place of Disposition ggVit.) Clymer(Off(Ao•—•
W (address)
Cl)
Qcc (section) at' (lot number (grave number)
Name of Sexton or Person in Charge of Premisesii �l' "
Z (p ase print)
w Signature Title [Q,do1
(over)
DOH-1555 (02/2004)