Dickenson, Michael Joseph 1
NEW YORK STATE DEPARTMENT OF HEALTH / Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Joseph Dickenson Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/25/2022 74 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Albany Street Address Albany Medical Center Hospital
Zia
Manner of Death 0 Natural Cause ❑Accident Homicide Suicide Undetermined riPending
W Circumstances Investigation
uJMedical Certifier Name Title
a Donghoon Lee
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
Ci ,Town or Village 0101 2785
Burial Date Cemetery,Crematory or Facility Name
11/30/
Addre2022 Pine View Crematorium
Entombment Address
▪Cremation Queensbury Town,New York
▪Donation
Removal Date Place Removed
F and/or and/or Held
VI Hold Address
O
a. Date Point of
(o Transportation Shipment
a 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
SRemains are Shipped,If Other than Above
' Address
IC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/30/2022 Registrar of Vital Statistics cDanieffe S giQespie(ECectronicaQy Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
A_____
WDate of Disposition 12 I Z t it Place of Disposition V„A�
2 (address)
W
CC (section/ / (lotpumber) (grave number)
rt
8 Name of Sexton or Person in Cha ises (/ IL~Z e print/
W oq
Signature Title (lo /71 l
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 'mot
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#