Sharkey, Michael NEW YORK STATE DEPARTMENT OF HEALTH E ,
Vital Records Section • _ Burial - Transit Permit
Name First
iddie Last Sex
Michael Patrick Sharkey Male
Date of Death Age If Veteran of U.S. Armed Forces,
t,. June 21, 2012 21 War or Dates
�' Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death❑ Natural Cause X❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
•= Circumstances Investigation
Medical Certifier Name Title
Ruth Scribner,
Address
55 Beckett Road Whitehall, NY 12887
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
June 22, 2012 Pine View Crematory
0 Entombment Address
.!®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Y; Date Point of
,; El Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
❑ Reinterment
ti
Date Cemetery Address
f
1 Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
"k 136 Main Street, South Glens Falls NY 12803
4 :. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ains described above 9s. i dicated.
4
Date Issued 6 a a/iz Registrar of Vital Statistics , 14
(signature)
District Numbers 7 5 Place 1 rum ct.fi hA o
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-
Date of Disposition 06/22/2012 Place of Disposition Quaker Road Queensbury,NY 12804
- (address)
?i?i
(section) (lot number) 1� (grave number)
Name of Sexton or rson in Ch a of Premises ( rzçir Ciwv11
please print)
Signature / Title C
(over)
DOH-1555 (02/2004)