Munoff, Joseph NEW YORK STATE DEPARTMENT OF HEALTH 1 ,fy 3
Vital Records Section Burial - Transit Permit
Name First Middle • Last' Sex
Joseph Anthony Murtliff Male
Al Date of Death Age If Veteran of U.S. Armed Forces,
June 9, 2013 78 War or Dates •
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 614 Clark Road
' Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson,
Address
'a 161 Carey Road Queensbury, NY 12804
m Death Certificate Filed District Number �j Register Number
V City, Town or Village Moreau < 6 2 ,1
k�'❑Burial Date Cemetery or Crematory f
June 11, 2013 Pine View Crematory
. ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
413T3-
❑ Disinterment Date Cemetery Address
In III Reinterment
Date Cemetery Address
t,
v Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
z Permission is hereby ranted to dispose of the human re ains described above as indicated.
Date Issued / J Registrar of Vital Statistics 14/J} d
U M. ta
(signature)
District Number y 7 Place 6,/ Ef UIi,Son/ Jr , ,-. Qt/7 C/.. 1 f4hL.l /V y A,2 J
TawL
al I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/11/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numb (grave number)
Name of Sexton or Person 'n Charge of Pr ises /I1ti r" ien44
((please print)
...= Signature Title «PTA
(over)
DOH-1555 (02/2004)