Carr, Michael # (t375
NEW YORK STATE DEPARTMENT OF HEALTH e -
Vital Records Section Burial - Transit Permit
Name First Middle Last j Sex
Michael R. Carr Male
Date of Death Age I If Veteran of U.S. Armed Forces,
August 17, 2012 58 War or Dates
I . Place of Death I Hospital, Institution or
Z City, Town or Village Queensbury Street Address 88 Forest Rd.
pManner of Death I XI Natural Cause I I Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
C Eric Pilleman,MD
Address
Glens Falls Hospital, Glens Falls,NY 12801
Death Certificate Filed District Number 1
1 Register Number
City, Town or Village Queensbury /0 O
❑Burial Date Cemetery or Crematory
August 27, 2012 Pine View Crematorium
❑ Entombment Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed -
Z Removal and/or Held
0 and/or Address
H Hold
(n
O j Date Point of
yTransportation j Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I IPermit Issued to Registration Number
Name of Funeral Home Regan & Denny Stafford Funeral Home 1 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
GC
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a
Permission is hereby granted to dispose of the human re ains described above a' indicated.
Date Issued 6-- au-,9-ut Z Registrar of Vital Statistics )4`
(signature)
District Number 5-� - Place Queensbury
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition If-to.it Place of Disposition Or-St..... C,v.torlt..
E (address)
W
N
re
0 (section) /j ` (lot number)e- (grave number)
QName of Sexton or Person in Charge Premises is fr r
Z (please print)
W AL
Signature Title CLr►+i4-r00
(over)
DOH-1555(02/2004)