Young, Michael William NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael William Young Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/25/2022 70 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p▪ Manner of Death ❑X Natural Cause EI Accident ❑Homicide Suicide 0 Undetermined ❑Pending
W Circumstances Investigation
WMedical Certifier Name Title
a 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 131
❑Burial Date Cemetery,Crematory or Facility Name
03/01/2022 Pine View Crematory
❑Entombment Address
•CI Cremation Queensbury Town,New York
ElDonation
oZZ 0 Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
a. Date Point of
UA ❑Transportation Shipment
p by Common
Carrier Destination
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
H Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/01/2022 Registrar of Vital Statistics Megan NofiingYectronicallySigned)
(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:
I-
Z Date of Disposition 31 2(27. Place of Disposition v..-- h/l or�•�"''—
W (address)
W
CC
N (section) (lot number) (grave number)
-,
0 Name of Sexton or Person in Charge of Premi ‘`s �
(Male print)
W Title 676 M �tta
Signature
DOH-1555(07/18)p 1 of 2
� 53wow
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#