Davis, Michael NEW YORK STATE DEPARTMENT OF HEALTH l
Vital Records Section Burial - Transit Permit
�r::; Name First Middle Last Sex
444 Michael Alfred Davis Male
:r:: Date of Death Age If Veteran of U.S. Armed Forces,
:r December 20,2014 69 War or Dates
1:4
Place of Death Hospital, Institution or
City, Town or Village Bolton Street Address 10 First Street
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
9 Paul R.Filion,MD
r Address
r , ,:Irongate Center Glens Falls New York
•
:, Death Certificate Filed District Number 5L0so Register Number lc
:_: City, Town or Village Town of Bolton
. ❑Burial Date Cemetery or Crematory
December 26, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
N
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
r.: Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
E. Remains are Shipped, If Other than Above
Address
:; Permission is hereby granted to dispose of the human remains de cribed above as 'ndicated.
Date Issued 4431 I V Registrar of Vital Statistics Ce'}---KA--
:;� (signature)
District Number 3G.56 Place Town of Bolton
I_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z t ����
w Date of Disposition 11/74{41 Place of Disposition �,,�.U, Crs r'...
(address)
N
CL (section) d (lot numb) (grave number)
pName of Sexton or Perso in Charge of Premises „ a+r11}
Z i (please print)
W •
Signature4--- Title 6:11 u:,441-t-k
(over)
DOH-1555(02/2004)