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Klein, Michael Peter 1.0F /1- tiqq NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Michael Peter Klein Male Date of Death Age If Veteran of U.S.Armed Forces, 12/06/2023 76 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Town Street Address 108 Sly Pond Road,Fort Ann Town,New York 12827 W Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation WMedical Certifier Name Title ID Aqeel Gillani MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 17 s Burial Date Cemetery,Crematory or Facility Name ...." 12/07/2023 Pine View Crematory „<-- Entombment — Address ©Cremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held i— Hold Address N 0 A. Date Point of (f)0Transportation by Common Shipment Carrier Destination Date Cemetery Address Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom }— 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 12/07/2023 Registrar of Vital Statistics Miranda.7ferringsfiaw(ECectronica((y Signed) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H WDate of Disposition 12 I gly Place of Disposition 4::7=rEi L-..) ( 14/41y -14, , 2 (address) W ft (section) (lot number) (grave number) Dz Name of Sexton or Person in Charge of Premises L/ ' A t:s k.-- A14,1 t / se rint) P P W Signature / Title M DOH-1555(07/18)p 1 of 2 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#