Levulis, Michael ft
NEW YORK STATE DEPARTMENT OF HEALTH /1
Vital Records Section i _ { Burial - Transit Permit
Name First Middle Last Sex
Michael Joseph Levulis Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 5, 2012 66 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Street Address Haynes House of Hope
0
Manner of Death 0 Natural Cause n Accident El Homicide El Suicide Ell Undetermined ri Pending
Circumstances Investigation
W
"3 Medical Certifier Name Title
Kevin Dooley, Dr.
Address
135 North Road Wilton, NY 12831
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
February 8, 2012 Pine View
Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
C Date Point of
Transportation Shipment
by Common Destination
o Carrier
Disinterment Date Cemetery Address
•
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0.1)(9&be t?, Registrar of Vital Statistics /N,,,tdtci ca. .,i
(signature)
District Number S7.(0 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/08/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) _ 11 (lot number) (grave number)
E Name of Sexton or Per n in Charge o Premises r,it`�N� J`�H
t (please print)
al Signature � oak);iv,kl-T04,
9 - Title
(over)
DOH-1555 (02/2004)