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Gifford, Michael Lee 1I N EW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael Lee Gifford Male Date of Death Age If Veteran of U.S.Armed Forces, 02/26/2023 82 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 15 Woodscape Drive, Moreau Town, New York 12828 IW Manner of Death Undetermined Pending El Natural Cause EAccident Homicide Suicide lL Circumstances Investigation W Medical Certifier Name Title John Mongan DO Address 3 Care Lane 300,Saratoga Springs,New York 12866 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 10 Burial Date Cemetery,Crematory or Facility Name 02/28/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held F Hold Address 0 n. Date Point of U)❑Transportation Shipment Q by Common Carrier Destination Date Cemetery Address Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls, New York 12803 Name of Funeral Firm Making Disposition or to Whom 1— 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 02/28/2023 Registrar of Vital Statistics Brenda Mutter(Electronically Signed) (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 31i j i? Place of Disposition 1' 2 (address) W CC CC (section) (lpt numb (grave number) Name of Sexton or Person in Charge of Premises '"NL ,-tv4 i t Z / lease print) W G- Title ra H Signature / DOH-1555(07/18)p 1 of 2 .,.. .° k Public Health Law Sec. 4145(2b) r . , Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on,burial permit Official Funeral Directors Reg.or License# •