Long, Michael Joesph # 137
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Joseph Long Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/01/2021 40 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Undetermined Pendin
W Natural Cause Accident ElE
Homicide Suicide g
Circumstances Investigation
W Medical Certifier Name Title
Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village- Glens Falls 5601 435
Burial Date Cemetery,Crematory or Facility Name
10/05/2021 Pine View Crematory
❑Entombment Address
lCremation Queensbury Town,New York
Li Donation
Removal Date Place Removed
and/or and/or Held
Hold Address
0
Date Point of
NL j Transportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
11;
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/05/2021 Registrar of Vital Statistics R96ertf7narrew Curtis.(''lectronicad:y Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition /D f b 14 Place of Disposition
W
2 (address)
W
U)
(sect/on) d (lot number) (grave number)
Name of Sexton or Person in Charge of P mises �tiv4�
(p e se print)
Z f
W Signature Title l r'J+iltb
DOH-1555(o7/18)p t of 2
ii 1 e 0 4
Public Health Law Sec. 4145(2b)
Receipt
Human remains of : delivered on • , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#