Bethel, Michael Edward 7/
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NEW YORK STATE DEPARTMENT OF HEALT f -- Burial - Transit Permit
Bureau of Vital Records
s
Name First Middle Last Sex
Michael Edward Bethel Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/18/2022 65 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
3� Manner of Death El Natural Cause EAccident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
1 Medical Certifier Name Title
Howard Silverberg MD
Address
100 Park St,Glens Falls, New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 580
Burial Date Cemetery,Crematory or Facility Name
11/21/2022 Pine View Crematory
Entombment
_ Address
Cremation Queensbury, New York
-p LiDonation
Removal
Date Place Removed
LI
1 and/or and/or Held
Hold Address
th
C)
Transportation Date Point of
3 by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/21/2022 Registrar of Vital Statistics Megan Wolin(ECectronica((ySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I1 1 23 h L Place of Disposition
1.1 _____
(address)
tal
Et (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises /r„ �p It
// (phase print)
Signature / ,c- Title l P-mil2
DOH-1555(07/18)p 1 of 2
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Public Health Law Sec. 4145(2b)
1
Receipt
1
Human remains of delivered on , 20
1 Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#