Seamon, Michael NEW YORK STATE DEPARTMENT OF HEALTH 1 g-/ Vei
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael J. Seamon Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 13, 2013 69 War or Dates Vietnam
F- Place of Death Hospital, Institution or
t1 City, Town or Village Moreau Street Address 7D Tanager Way
13 Manner of Death❑ Natural Cause LI Accident El Homicide ID Suicide ElUndetermined Pending
Ili
Circumstances Investigation
W Medical Certifier Name Title
Ci Michael Sikirica MD,
= Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village L/ _6 Z l�
❑Burial Date Cemetery or Crematory
March 18, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z` ri Removal and/or Held
and/or Address
Hold
CO Date Point of
CI
0 Transportation Shipment
(t) by Common Destination
in Carrier
LiDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
W.
0L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 J/,3 J/_3 Registrar of Vital Statistics C.:0M/}tL I o/, aLab.t '
(signature)
District Number 4�j 2, Place 6, / I-/LJ c n1 Sr• Jb Li 774 6LENLS Fig j L s LU V I 25 a 3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
> (,/.:
W Date of Disposition 13 Place of Disposition ��/� t= /
(address)
Wit;
nu er) (grave number)
(section) �� �� d
Name of Sexton Per n i ge of Premises
/�
(please print)
l!<! Signature Title C/Cr6- i
(over)
DOH-1555 (02/2004)