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Shields 111, Joseph Patrick itlt NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records • Name First Middle Last Sex • Joseph Patrick Shiels III Male Date of Death Age If Veteran of U.S.Armed Forces, 09/17/2021 74 Years War or Dates 1966-1969 • H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital Ili p Manner of Death © Natural Cause 0 Accident E Homicide El Suicide 0 Undetermined 0 Pending W C.) Circumstances Investigation W Medical Certifier Name Title O Howard Silverberg MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number • City,Town or Village Glens Falls 5601 404 ❑Burial Date Cemetery,Crematory or Facility Name • • • 09/20/2021 Pine View Crematory 71 El Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Z• Removal Date Place Removed and/or and/or Held ~ Hold Address , Cl) O Date Point of (/) L j Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address D Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom i- Remains are Shipped,If Other than Above 2 Address W n' Permission is hereby granted to dispose of the human remains described above as indicated. • Date Issued 09/20/2021 Registrar of Vital Statistics Men Andrew Curtis(ECectronicalry Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: (-IW /address/ Z Date of Disposition l izl i Zi Place of Disposition RM W Cl) (section) / (lot number) (grave number! O• Name of Sexton or Person in Charge of Pre ises [ "t,A �i t Z (p ase print) W Signature 6Y •---"-- Title � ���� DOH-1555(07/18)p 1 of 2 1.5 Public Health Law Sec. 4145(2b) r � Receipt Human remains of delivered on , 20 t!1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#