Thornton, Michael Elliott 4Pi$
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Elliott Thornton Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/15/2022 58 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide D Undetermined 1=1 Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 44
Burial Date Cemetery,Crematory or Facility Name
01/24/2022 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
O O. Date Point of
(o ❑Transportation Shipment
p by Common
Carrier Destination
El
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
a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/19/2022 Registrar of Vital Statistics Megan NoCsrr(EkectronicalTSWned)
(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:
H
WDate of Disposition I l25 iZ2 Place of Disposition - V- r:-
2 (address)
W
EC (section) (lot number) ( (grave number)
S Name of Sexton or Person in Charge of Pr ises J ,“
� /p/ e print/
W Signature Title (ripA14 )4.
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
-Rine View Cemetery Representing the funeral home named:on burial permit
Official Funeral Directors Reg.or License#