Tucker, Michael •
NEW YORK STATE DEPARTMENT OF HEALTH (o l-/
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael L. Tucker Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 19, 2012 56 War or Dates
` Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address Evergreen Court
0' Manner of Death
X Natural Cause Accident ( I Homicide Suicide Undetermined Pending
US Circumstances Investigation
1, Medical Certifier Name Title
Michael Sikirica,MD
Address
' 50 Broad Street,Waterford,NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Moreau A..
❑Burial Date Cemetery or Crematory
❑Entombment November 21, 2012 Pine View Crematorium
Address
Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
F" Hold
N
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls, NY 12803
' Name of Funeral Firm Making Disposition or to Whom
! * Remains are Shipped, If Other than Above
2 Address
Ce
W`
11` Permission is hereby granted to dispose of the human remains described above a indicated.
Date Issued //4/-aP/ Registrar of Vital Statistics /; c-
signature)
District Number 4`Aso,, Place Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition ,t /7C/IZ Place of Disposition fre U ,,, ��w,,, tiv"
2 (address)
W
N
CC (section) ` •' -(lot number) ( (grave number)
O Name of Sexton or Person in Charge of Premises
G 9 f,3•�� • eN+,cfC
Z (pldase print)
W
Signature Title tnlllloyp
(over)
DOH-1555(02/2004)