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Stockwell, Michael Allen 1759 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael Allen Stockwell Male Date of Death Age If Veteran of U.S.Armed Forces, 12/06/2020 51 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address Melbourne Avenue,Hudson Falls Village,New York 12839 Manner of Death © 1=1Undetermined El Pending W Natural Cause Accident Homicide Suicide Circumstances Investigation W Medical Certifier Name Title Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 38 ❑Burial Date Cemetery,Crematory or Facility Name 12/08/2020 Pine View Crematorium • ❑Entombment Address X❑Cremation Queensbury Town,New York Donation ZZ ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 d Date Point of (I) j Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped,If Other than Above 5 Address CC W o' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/08/2020 Registrar of Vital Statistics Cynthia Bard n(ECectronica1tySigned) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H f �Z Date of Disposition 12 I'I to Place of Disposition 2 (address) W /section/ /!ot numbe (grave number) °` t Name of Sexton or Person in Charg f Premises 4��l� Z (plea print) /' W Signature mar— Title ` fpvL DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014 2 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit cial Funeral Directors Reg.or License# ,