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Daus, Michael NEW YORK STATE DEPARTMENT OF HEALTH I/ yob Vital Records Section Burial - Transit Permit Name First Middle Last Sex Mi chap1 ..• DauG Mal' Date of Death Age If Veteran of U.S. Armed Forces, 0 6/01 /2 01 6 6 2 War or Dates Place of Death Hospital, Institution or Z C# Mown or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending O. Circumstances Investigation tu Medical Certifier Name Title 0: Sean Bain MD Address 100 Park St. Glens Falls , NY 12801 giiiii Death Certificate Filed District Number Register Numbe may, Town or Village Glens Fa 11 s F 20 t p� ❑Burial Date Cemetery or Crematory 06/03/2016 Pine View Crematory 0 Entombment Address imi!iiillciCremation 21 Quaker Rd. Queensbury, NY12804 Date Place Removed Z n Removal and/or Held '2 and/or Address H Hold tel 0. Date Point of ❑Transportation Shipment 25 by Common Destination Carrier ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to MB Kilmer Funeral Home Registration Number Name of Funeral Home 01 078 .< Address 136 Main St. So, Glens Falls, NY 12803 • Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address c Lit Permission is hereby granted to dispose of the human remains described above as in a d. Date Issued CO/2©/1- Registrar of Vital Statistics i7 . (signature) District Number ;-60/ Place �',et,-7>., ,/-5, ky i certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 W Date of Disposition (olio/A Place of Disposition gi(LP ("1"114,10N (address) W CO CC (section) if (lot number) (grave number) ci Name of Sexton or Person in Charge of Premises i(1.31UP ) 6 A (pl ase print) Signature Title Cpi►4 (over) DOH-1555 (02/2004)