Gilligan, Michael Patrick # 3
•
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of VitaE Records
Name First Middle Last Sex
Michael Patrick Gilligan Male
Date of Death Age If Veteran of U.S.Armed Forces,
isi;2/28/2021 67 Years War or Dates 1972-1974'
lace of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause p Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
C)
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 639
Burial Date Cemetery,Crematory or Facility Name
12/30/2021 Pine View Crematorium
ElEntombment Address
ElCremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
u) ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 •
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/30/2021 Registrar of Vital Statistics Rp6ertAndrew Curtis(E(ectronicalTy 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:
W Date of Disposition /1I21 Place of Disposition 1.c l4-- �- fa,---
2 (addddress)
W
N (section) (lot number) (grave number)
S Name of Sexton or Person in Char f Premises r`S ,��Ak
tt-
z ((ease print)
W Signature Title ", �
DOH-1555(07/18)p 1 of 2
1 Public Health Law Sec. 4145(2b)
1
Receipt
Human remains of _ ^'delivered on • , 20
1
1
1
Pine View Cemetery Representing the funeral home named on,burial permit
Official Funeral Directors Reg.or License#