Harvey, Michael Thomas NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Thomas Harvey Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/27/2021 64 Years War or Dates
1., Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address 75 Briwood Circle,Queensbury Town, New York 12804
'p Manner of Death ❑X Natural Cause El Accident Homicide ElSuicide Undetermined Pending
U Circumstances Investigation
uJ Medical Certifier Name Title
Lynn Keil PA
Address
1340 State Rt 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 200
0 Burial Date Cemetery,Crematory or Facility Name
09/29/2021 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
DDonation
cs El Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
(I) Li Transportation
p by Common Shipment
Carrier Destination
Disinterment 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
Remains are Shipped,If Other than Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/29/2021 Registrar of Vital Statistics Carnlinexllegarde Barger((lectrnnica45/5zgned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ,I3c i Place of Disposition t (,.
2 (address)
W
(!)
(section) (lot num (grave number)
O Name of Sexton or Person in Charge of Premises
l'pase print)
W Signature Title f r-i1i/+*bt
DOH-1555(07/18)p 1 of 2
•Public Health Law Sec. 4145(2b)
I
Receipt
t
9 Human remains of j delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
•fficial Funeral Directors Reg.or License# I !_ -