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Sims, Michael R ift"71v ... , , LF NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael R Sims Male Date of Death Age If Veteran of U.S.Armed Forces, 08/30/2023 67 Years War or Dates Army i_ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital ILI p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Circumstances Medical Certifier Name Title O Asim Chaudry 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 410 Burial Date Cemetery,Crematory or Facility Name 09/02/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held pN Hold Address 0 O. Date Point of (/) Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom N Remains are Shipped,If Other than Above 5. Address Q W 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/01/2023 Registrar of Vital Statistics Megan Nolin(ECectronicallySigned) (signature) a 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— W p Date of Disposition i'i i Z3 Place of Disposition F,.(t 4g--, 2 (address) W N (section) iot number) (grave number) Name of Sexton or Person in Charge of Pre ises e• L 0 (p/ea rint) W Signature - Title DOH-1555(07/18)p 1 of 2 v,: ri7` O Public Health Law Sec. 4145(2b) Receipt 1 1 I Human remains of delivered on ?: , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#