Graham, Michael Charles # (1a
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Charles Graham Male
Date of Death Age If Veteran of U.S.Armes • ces,
01/06/2022 76 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
Q Manner of Death Natural Cause ❑Accident Ei Homicide ❑Suicide 0 Undetermined ❑Pending
IJi Circumstances Investigation
LUMedical Certifier Name Title
Scott Biasetti MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 19
Burial Date Cemetery,Crematory orFeell<N me
01/11/2022 Pine View Crematorium
❑Entombment Address
X❑Cremation Queensbury Town,New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
H Hold Address
to
0
O. Date Point of
U) ❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
Date Cemetery Address
❑Reinterment
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
Remains are Shipped,If Other than Above
2 Address
CC
LU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/10/2022 Registrar of Vital Statistics Megan Wolin(ECectronicalTySigned)
(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 I jI (ZZ Place of Disposition � L. G�..1tvf%J�
ddress/
W
CC N (section) /fl
(lot numb r, (grave number)
SName of Sexton or Person in Charge of Premi s R%
6 (plea print) rr,/�
lL Signature Title C( 1
DOH-1555(07/18)p 1 of 2
C15542
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#