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Bemis, Joshua NEW YORK STATE DEPARTMENT OF HEALTH R ' Z' Vital Records Section Burial - Transit Permit Name First Middle Last Sex Joshua Edwards Bemis Male Date of Death Age If Veteran of U.S. Armed Forces, January 1, 2017 35 War or Dates f- Place of Death Hospital, Institution or Z Ili City, Town or Village Glens Falls Street Address Glens Falls Hospital CI Manner of Death Natural Cause X❑ Accident ❑ Homicide I I Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title Timothy Murphy, Address 52 Haviland Ave Glens Falls, NY 12801 Death Certificate Filed District Num a Register Number City, Town or Village Glens Falls 01/ ❑ Burial Date Cemetery or Crematory January 6, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address F Hold Date Point of u ❑Transportation Shipment CO by Common Destination ❑ Carrier Date Cemetery Address ❑ Disinterment111 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address W Et' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued I 3 / 2Q i'7 Registrar of Vital Statistics L ..) ^.�.�a-r�-e rr.. ('�c p� (signature) District Number bc)1 Place V CQN t' �S \\ S , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 01/06/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W (section) A (lot number) c (grave number) Qp Name of Sexton or Person in Charge of Premises /;. (Tease print) W Signature ( Title C 1041, (over) DOH-1555 (02/2004)