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Kieman, Michael Scott
.. ,„q_...1. 6) 44. 5—S13 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit r Name First Middle Last Sex 'Michael Scott Kiernan Male Date of Death Age If Veteran of U.S.Armed Forces, 0718/2023 61 Years War or Dates l� Place of Death Hospital,Institution or Z City,Town or Village Schenectady Street Address Ellis Hospital ILI p Manner of Death El Natural Cause Accident 0 Homicide nSuicide Undetermined ❑Pending W V Circumstances Investigation G Medical Certifier Name Title Johnathan Sun DO Address 1101 Nott St,Schenectady,New York 12308 Death Certificate Filed City Of Schenectady District Number Register Number City,Town or Village 4601 538 BurialH Date Cemetery,Crematory or Facility Name 07/11/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held l— Hold Address N 0 E- Date Point of rA❑Transportation fa Common Shipment Carrier Destination oDisinterment Date Cemetery Address 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 5 Address CC W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/10/2023 Registrar of Vital Statistics Samanta R.Mykoo(Electronically Signed) (signature) District Number 4601 Place City Of Schenectady I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— J Z Date of Disposition "7(l( I1,3 Place of Disposition -F,,,v__W (address) W Cl)CCg /sect l 1ion/ /lotia�...� u umber� (grave number) S Name of Sexton or Person in Char '1 e o .mises Z Tease print) lJJ Signature Title + raf�nH�‹ DOH-1555(07/18)p 1 of 2 1 Public Health Law Sec. 4145(2b) f Receipt Human remains of delivered on , 20�- Pine View Cemetery Representing the:funeral home named on burial permit Official Funeral Directors Reg.or License# •