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Andersen, Michael NEW YORK STATE DEPARTMENT OF HEALTH f' * I Vital Records Section Burial - Transit P rmit Name First Middle Last Sex Michael A, Andersen Male Date of Death Age If Veteran of U.S. Armed Forces, mi 1 1 /1 6/201 4 65 yrs. War or Dates 1 970-1 970 Place of Death Hospital, Institution or City, Town or VillageTown of StreetAddress Add y Putnam Station62 Backus Lane 1 Manner of Death ©Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Richard McKeever M.D. _ Address giiii 102 R.ac2 Track Road, Ticonderoga, NY 12883 Death Certificate Filed Town of District Number Register Number < City, Town or Village Putnam Station 5763 Date Cemetery or Crematory ❑Burial 1 1 /1 8/2 01 4 Pine View Crematory Address X Cremation Oueensbury, New York Date Place Removed Removal and/or Held • • and/or Address Hold Q Date Point of N❑Transportation Shipment a by Common Destination Carrier El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Wilcox & Regan funeral home 01 821 Address 11 Algonkin St. , Ticonderoga, NY 12883 ''` Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped, If Other than Above Address gl Mi Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 1 1 /1 8/2 01 4 Registrar of Vital Statistics PG:� .�,tc-e.-J 2/hv (signature) << District Number 5 7(0 3 Place Town of Putnam Station I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition it/f4�ly Place of Disposition r.U,,..o Crv-iter +^ 2 (address) W Cl) _ CC (section) tt number) (grave number) 0 Name of Sexton or Person in Charge of Premises s Sa+. g rr (please print) 4 Signature G� 4.,._- Title _ CM-OW, DOH-1555 (10/89) p. 1 of 2 VS-61