Dickinson, Michael Richard NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Richard Dickinson Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/19/2021 75 Years War or Dates Marines
!- Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
111
Manner of Death I1 Natural Cause ❑Accident ❑Homicide III Suicide ❑Undetermined ❑Pending
Circumstances Investigation
QMedical Certifier Name Title
Kelly Maley PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 619
ElBurial Date Cemetery,Crematory or Facility Name
12/22/2021 Pine View Crematory
Entombment Address
O Cremation Queensbury,New York
▪Donation
Removal Date Place Removed
-- and/or and/or Held
H
N Hold Address
0
d Date Point of
❑
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Transportation
5 by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
.2 Address
it
W
D.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/22/2021 Registrar of Vital Statistics 906ert/YrufrewCurtii(E/ctronicall: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:
WDateof Disposition 12123 Ili Place of Disposition i td , fit"a... --_ -
2 (address)
W
NIC (section) (lot number) 44 (grave number)
c4
(t 6
g Name of Sexton or Person in Charge of Premises ''t
ti-
Z /�� /p! se print) /�
W Signature !� i`� Title y���� ��
DOH-1555(07/18)p 1 of 2
0 1 5 it ;
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#