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Draper, Michael Howard
# (9t1 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael Howard Draper Male Date of Death Age If Veteran of U.S.Armed Forces, 08/19/2023 68 Years War or Dates (... Place of Death Hospital,Institution or WCity,Town or Village Horicon Town Street Address 1195 Valentine Pond Road,Horicon Town,New York 12808 p Manner of Death ®Natural Cause ❑Accident Li Homicide Suicide Undetermined Pending tU C.) Circumstances Investigation ILI 0 Medical Certifier Name Title Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Horicon District Number Register Number City,Town or Village 5654 4 Burial Date Cemetery,Crematory or Facility Name ® 08/21/2023 Pine View Crematorium Entombment _ Address ©Cremation Queensbury Town,New York EDohation 0❑Removal Date Place Removed H and/or and/or Held N Hold Address 0 O. Date Point of CO Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/20/2023 Registrar of Vital Statistics 7(rista G Wood-(ElectronwaCCy Signed) (signature) District Number 5654 Place Town Of Horicon I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Date Date of Disposition $,Zl 1 Z3 Place of Disposition l i� L (. It.— 2 (address) W N O (section) (lot number) (grave number) r.0 Name of Sexton or Person in Cha f Premises X,1V_ .,l� Z (pl se print) W Signature Title 41 ( DOH-1555(07/18)p 1 of 2 017210 Public Health Law Sec. 4145(2b) Receipt Human remains of ? -. delivered on ' / / , 20.s) Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#