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Mandolare, Joseph NEW YORK STATE DEPARTMENT OF HEALTH e ' N I Vital Records Section Burial - Transit Permit Name First Middle Last Sex Joseph Vern Mandolare Male Date of Death Age If Veteran of U.S. Armed Forces, April 25, 2017 62 War or Dates Place of Death Hospital, Institution or w City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home CI Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation ILI® Medical Certifier Name Title Philip J. Gara, Dr. Address 318 Broadway Fort Edward 12828 Death Certificate Filed District Number Register�mber City, Town or Village Fort Edward 5-) ❑Burial Date Cemetery or Crematory April 26, 2017 Pine View Crematory <.❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held o and/orE Hold Address 0 Date Point of 1 Transportation Shipment tl by Common Destination Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment 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 2 Remains are Shipped, If Other than Above Address Ce Permission is her by gr nted to dispose of the human ra�'ns described above indicated. Date Issued ' (o / ? Registrar of Vital Statistics/, P J_ � (signature District Number57s� Place L ��c..c%cil I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 11 Date of Disposition 04/26/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) 111 tr (section) ,`/ (lot numbe (grave number) • Name of Sexton or Person in Charge of Premises t//�ts I+r -31411fr � please print) SignatureLi 4 Title ittco1�lama_ (over) DOH-1555 (02/2004)