Morency Sr, Michael a
/I6-Ill
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Traisit Permit
Name First Middle Last Sex
Michael Joseph Morency Sr. Male
<_ Date of Death Age If Veteran of U.S. Armed Forces,
September 18, 2016 68 War or Dates
i Place of Death Hospital, Institution or
WCity, Town or Village Hudson Falls Street Address 4 Stephan Drive
Manner of Death X❑Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
in Circumstances Investigation
Medical Certifier Name Title
0 Charles Yun, M.D Dr.
Address
Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village ..-T t ‘,,
❑Burial Date Cemetery or Crematory
September 21, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
7 1-1 Removal and/or Held
C and/or Address
F, Hold
Cil Date Point of
a. ❑Transportation Shipment
to by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
' 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
F Remains are Shipped, If Other than Above
Address
a. Permission is hereby ranted to dispose of the human re ain described above as indicated.
Date Issued -91 te. Registrar of Vital Statistics ,,''� (2 ).(..:1..4._, <
(signature)
District Number _ 4, ;A Place �� \ ),
�
' ) 7V6----)-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uJ Date of Disposition 09/21/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Ili
lir
(section) /� (lot number) (grave number)
Name of Sexton or Person in Charge of Premises C r, 4-. Sthtie
k, (please print)
U Signature L'L Title (17-Eilet
(over)
DOH-1555 (02/2004)