Case, Michael NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section r Burial - Transit Permit
Name First Middle Last Sex
Michael J. Case Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 22, 2014 54 War or Dates
Plac- --th n��f� Hospital, Institution or
r - City, own 'r Village q.. Street Address 815 McDougall Road
s Mann- of Death E Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
a
- ° Circumstances Investigation
Medical Certifier Name Title
Max Crossman, M.D. Dr.
Address
65 Poultney Steet Whitehall, NY 12887
Death '-;i ate Filed ���) District Number Register Number
City, ow .rVillage 'j`Io
0 Buna Date Cemetery or Crematory
August 25, 2014 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
ix
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
_ by Common Destination
Carrier
; Date Cemetery Address
❑ Disinterment
-❑ Reinterment
Date Cemetery Address
w Permit Issued to Registration Number
_ Name of Funeral Home M. B. Kilmer Funeral Home 01077
4 Address
42
123 Main St., Argyle NY 12809
h 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 hum ains describe above as i icated.
hX Date Issued K-Z ,-ac,N, Registrar of Vital Statistics 1,,--
(signature)
. District Number S-VaJ Place ,,_
s4 _9___
F I certify that the remains of the decedent identifie above were disposed of in accordance with this permit on:
Date of Disposition 08/25/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises A, I SA•J
;'% (,ler ase print)
Signature Z" 2✓ Title C Vs
(over)
DOH-1555 (02/2004)