Mihill, Michael NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit-Permit
Name First Middle Last Sex
MICHAEL R. MIHIL,L MALE
Date of Death Age If Veteran of U.S. Armed Forces,
10/27/11 36 War or Dates
j: Place of Death Hospital, Institution or
-Gitp, Town or ViiiagQ NORTH ELBA Street Address AMC [JIHLEIN MERCY CENTER
itict Manner of Death w Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
W. Circumstances Investigation
tu Medical Certifier Name Title
JESUS C. SERRANO, MD
Address
UIHLEIN MERCY CENTER LAKE PLACID, NY
Death Certificate Filed District Number Register Number
►Lit ejwitraC+4itatge NORTH ELBA 1560
❑Burial Date Cemetery or Crematory
NOV. 2, 2011 PINE VIEW CREMATORY
Entombment Address
' i['Cremation GLENS FALLS, NY
Date Place Removed
4 ri❑Removal and/or Held
and/or Address
h Hold
to
0 Date Point of
CL p Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. CLARK, INC. 01094
Address
2310 SARANAC AVE. , LAKE PLACID, NY 12946
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
0
LEI
Permission is hereby granted to dispose of the human rem ' s described above as indicated.
Date Issued 10/2 9/11 Registrar of Vital Statistics 1/Ait(Luf,/c,Liz l
(signet/re)
District Number 1560 Place �/.0A/ a{' e-r-i Lag
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition Ii j311\ Place of Disposition T i 14 tilituj Crt r' F0r:v,_
2 (address)
Ui
U)
C (section) (lot number) (grave number)
cName of Sexton or erson in Chargeof Premises4 I isk —�t"`L
(please print)
ILI
Signature Title CQY tV\ L
(over)
DOH-1555 (02/2004)