Young, Michael Joseph ICFM I Sc.-
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Joseph Young Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/10/2023 67 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
WW Manner of Death ❑ Unetermne
Natural Cause »Accident Homicide Suicide d id n Pending
U Circumstances Investigation
W Medical Certifier Name Title
Gamal Khalifa 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 78
Burial Date Cemetery,Crematory or Facility Name
02/13/2023 Plne View Crematory
»Entombment Address
»Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
- and/or and/or Held
H- Hold Address
N
0
d Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
»Disinterment
Date Cemetery Address
E Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/13/2023 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(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:
l—
Z Date of Disposition Z—6=Zaz 3 Place of Disposition ��A)g �`pJ �-��J 4114
2 (address)
uJ
CC (section) (lot num er) (grave number)
0 Name of Sexton or Person in Charge of P ises T,/0/dv' ae
Z _((please print)
W Signature .. ` Title ftr�i�i
DOH-1555(07/18)p t of 2
7 n 4
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#