Michon, Richard Z (f....
NEW YORK STATE DEPARTMENT OF HEALTH , --,r Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard William Michon Male
Date of Death Age If Veteran of U.S.Armed Forces,
�' March 23, 2015 87 War or Dates World War II
''' I iPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 3 Broad Street Plaza
Manner of Death Natural Cause 0 Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
14
;� Circumstances Investigation
14 Medical Certifier Name Title
Joseph C. Mihindu, MD,
Address
20 Murray Street Glens Falls, NY 12801
' Death Certificate Filed District Number Register Number
'x C) City, Town or Village 5601 ((
1,
0 Burial Date Cemetery or Crematory
March 25, 2015 Pine View Crematorium
0 Entombment Address
,; ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
wr' ❑ Removal and/or Held
and/or Address
3
Hold St. Paul's Cemetery
401,1
Date Point of
a°`€ ❑Transportation Shipment
4 by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
`E ❑ Renterment Date Cemetery Address
r Permit Issued to Registration Number
` Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
AO? Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Xki Name of Funeral Firm Making Disposition or to Whom
re Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ains des ibed above as indicate
Registrar of Vital Statistics
Date Issued �3 9 ��' f, '�7 ��.
A pce % f (signature)
District Number 5601 Place
A
i
Yi I certify that the remains LLof the decedent identified above were sposed of in accordance with this ermit on:
Date of Disposition 03/2R/2015 Place of Disposition Quaker Road Queensbury,NY 12804/ut iiic . .
(address)
OP
',; (section) t nu ) (grave number)
gl Name of Sexton or i Charg of Premises L T � w//h-i
(pleasnt)
Signature Title 7/ +2 /4/57't_
(over)
DOH-1555 (02/2004)