Celeste, Michael NEW YORK STATE DEPARTMENTtOF HEALTH , _ _* p ZZko
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael Joseph Celeste Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 29, 2011 71 War or Dates is6a- \g(py
Place of Death Hospital, Institution or
City, Town or Village South Glens Falls Street Address 9 Pine View Drive
Manner of Death Natural Cause 0 Accident 0 Homicide Suicide ril Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Mark Hoffman, Dr.
Address
102 Park Street Glens Falls, NY 12801
w Death Certificate Filed District Number 21� Z Register N u mber
Ci Town or Village
❑Burial Date Cemetery or Crematory
May 2, 2011 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
t Date Place Removed
Removal and/or Held
and/or Hold Address
Date Point of
Transportation Shipment
by Common Destination
art Carrier
Disinterment Date Cemetery Address iii
_ ElReinterment Date Cemetery Address
z: Permit Issued to
Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01097
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
fi: Address
g
A
Permission is hereby granted to dispose of the human remains described above as i icated.
Date Issued ,5 / ) 1) Registrar of Vital Statistics- ��i{1/n.( rn ,t'„(J �I//{J�/�v��++//I
(signature)
District Number `7 570,2 Place 6./}-/U)JS u /.) 5T. k_501,/ T/-t C GC-Ms FALIJ ,)N /,7SO 3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/02/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
vs-
Name of Sexton or rson in Charg of Premises Lh ri i Ri►i+r St 4,4 if
I (please print)
kr
,. Signature Title Cri VWI0 rt.
(over)
DOH-1555 (02/2004)