O'Connor, Michael NEW YORK STATE DEPARTMENT OF HEALTH' / Dc
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael J. O'Connor Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 26, 2012 90 War or Dates
1_; Place of Death Hospital, Institution or
Z City, Town or Village Street Address Glens Falls Hospital
cManner of Death LriNatural Cause ❑Accident Homicide n Suicide n Undetermined n Pending
W Circumstances Investigation
ui Medical Certifier CI Namer Title
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Death Certificate Filed Di trict Number Register Number
City, Town or Village Glens Falls 5601 Jr ci 9
❑Burial Date Cemetery or Crematory
December 28, 2012 Pine View Crematorium
❑Entombment Address
❑X Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
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0 Date Point of
116 n Transportation Shipment
p by Common Destination
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Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Stafford Funeral Home 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
g Address
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A. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7 Z./ Zi3/1 2 Registrar of Vital Statistics t-"JC.A.l. ,-.Tt (N
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 11-16•-(L Place of Disposition -F•jsri ui 6 anu.:
W (address)
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CL (section) A (lot number),. (grave number)
QName of Sexton or Person in Charge of Premises Llir,�}
Z I(please print)
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Signature Title CIQp1M14i41-
(over)
DOH-1555(02/2004)