Andrews, Michael Robert 512.
NEW YORK STATE DEPARTMENT OFhHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Robert Andrews Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/13/2021 73 Years War or Dates 1966-1968
▪ Place of Death Hospital,Institution or
W City,Town or Village South Glens Falls Village Street Address 129 Saratoga Road 102,South Glens Falls Village,New York 12803
• Manner of Death Natural Cause Accident ❑Homicide Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 John Lukaszewicz MD
Address
101 Ridge Street 2,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village South Glens Falls Village 4524 19
Burial Date Cemetery,Crematory or Facility Name
07/15/2021 Pine View Crematory
Entombment Address
111 Cremation Queensbury Town,New York
Donation
Date Place Removed
▪ and/orRemoval and/or Held
Hold Address
0
a Date Point of
Cl) LiTransportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/14/2021 Registrar of Vital Statistics joy BarthoComew(ECectronicaCCy Signed)
(signature)
District Number 4524 Place South Glens Falls Village, New York
t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
W Date of Disposition 7/n/ 4 Place of Disposition pi'fk[� �r4J �('e,,,t,caGcy'
I (address)
W
N CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises JC1'+" ' Sgt'r`k3(please print)
Z ) r
lL Signature Title Crtmcrk0
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01 4(490
Receipt
Human remains of `- delivered on ° P , 20
ji
Pine View Cemetery Representing the funeral home named on burialpermit
Official Funeral Directors Reg.or License# '