Molisani, Michael NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section Burial - Transit Permit
i
gE Name First Middle Last Sex
MICHAEL WARP rvinLISANI Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 13, 2016 59 War or Dates n/a
14 Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending
Circumstances Investigation
tu Medical Certifier r Name , Title
Ls
�SS�
Death Certificate Filed ` District Number Register N.mber
iM City, Town or Village Glens Falls, nY 5601 I 3
> El Burial Date Cemetery or Crematory
November 15, 2016 Pine View Crematory
r'i D Entombment Address
[cremation Quaker Rd Queensbury, NY
Date Place Removed
❑and/or Address
Removal and/or Held
Hold
5f,,� Date Point of
Transportation Shipment
Gs by Common Destination
mi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
>< Address
53 Quaker Rd Queensbury, NY 12804
Mg Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
2
in
'` Permission is hereby granted to dispose of the human remains described above as indicated.
Fili Date Issued 11/14/16 Registrar of Vital Statistics VJCAA,Ary-NR.
(sign ure)
Kig District Number 5601 Place City of Glens Falls, NY 12804
,.::::::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
� i / ll
i� Date of Disposition j it i 71)6, Place of Disposition . ! ' 1R, v A e 0 C-N..t h,, Toe , ti.",,_t
2 (address)
iti
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises CI-fy A✓icy he+."el.-n7r
/ (please print)
Signature of i, Title ,e,. ,,,-
(over)
DOH-1555 (02/2004)