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Croissant, Michael W NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael W.Croissant Male Date of Death Age If Veteran of U.S.Armed Forces, 10/25/2021 70 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death © Natural Cause ❑Accident ❑Homicide El Suicide Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title C Mathew Varughese DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 460 Burial Date Cemetery,Crematory or Facility Name 10/27/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York ❑Donation Z Removal Date Place Removed and/or and/or Held Hold Address 0 Date Point of Cl) Li Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom f. Remains are Shipped,If Other than Above a Address EC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/26/2021 Registrar of Vital Statistics Men Anirew Curtis(Electronically 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: Z Date of Disposition Nit, It Place of Disposition ttlt- (address/�J/f ..—W CO CC (section) dtr,teL., (lot num / (grave number) 8 Name of Sexton or Person in Cha f Premises � ,. (please print/ W hsTriyt Signature Title C tt DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) 015258 Receipt Human remains of ' �T S''1'1 delivered on , 20 9 Pine View Cemetery Representing the funeral home named on•bu,rial pemit Official Funeral Directors Reg. or License# • ` ,>-L