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Primeau, Michael NEW YORK STATE DEPARTMENT OF HEALTH 0 Vital Records Section Burial - 1 ransit Permit Name First Middle Last Sex Michael Primeau Male Date of Death Age If Veteran of U.S. Armed Forces, January 25, 2014 66 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title David Cunningham, Dr. Address 3 Irongate Glens Falls, NY 12801 Death Certificate Filed District Number C G© 1 Register Number` City, Town or Village Glens Falls J ❑Burial Date Cemetery or Crematory January 27, 2014 Pine View Crematory ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home 01078 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 Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued t l I y Registrar of Vital Statistics C,- p. WA-"-cO- ' (signature) District Number 5b O f Place G (Qic'-c C0 t1 5 /) CJ i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 01/27/2014 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot numb) (grave number) Name of Sexton or Person i Charge o Premises (IL tuiti please print) Signature / Title egEliiirGe (over) DOH-1555 (02/2004)