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Mangan, Michael NEW YORK STATE DEPARTMENT OF HEALTH e 4- ), 4rlltd Vital Records Section Burial - Transit Permit =, Name First Middle Last Sex Michael R. Mangan Male Date of Death Age If Veteran of U.S. Armed Forces, February 26, 2012 67 War or Dates Vietnam Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death rcrl.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending Circumstances Investigation Medical Certifier Name Title Dean Reali, Dr. Address 3767 Main St. Warrensburg, NY 12885 n Death Certificate Filed District Number Register Number City, Town or Village E 6 01 1 J ❑Burial Date Cemetery or Crematory March 1, 2012 Pine View - ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of E ❑Transportation Shipment by Common Destination Carrier :`'' Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address may:• 4, Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01096 • Address 123 Main St., Argyle NY 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 4 Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 2/ 21S 112 Registrar of Vital Statistics W c t,,v,,,_Q W-A,.. (signature) District Number56© I Place 6 S Vo,\\-,1 J\I • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 03/01/2012 Place of Disposition Quaker Road Queensbury,NY 12804 (address) ;° (section) (lot number)r (grave number) Name of Sexton or Pe on in Char of Premises Iran} r ..)t14- / (please print) Signature jfL _ Title CVEmA--co(l, (over) DOH-1555 (02/2004)