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Kovarilk, Michael William NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Michael William Kovarik Male Date of Death Age If Veteran of U.S.Armed Forces, 09/22/2021 65 Years War or Dates (H Place of Death Hospital,Institution or W City,Town or Village Greenwich Town Street Address 219 Ryan Road,Greenwich Town,New York 12834 1p Manner of Death © Natural Cause D Accident Homicide Suicide 0 Undetermined Pending Circumstances Investigation W• Medical Certifier Name Title O Patricia Stott NP Address 43 New Scotland Avenue MC7,Albany,New York 12203 Death Certificate Filed District Number Register Number City,Town or Village Greenwich 5757 22 ❑Burial Date Cemetery,Crematory or Facility Name 09/24/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ElDonation Z 0 Removal Date Place Removed and/or and/or Held _. H Hold Address N O Date Point of (/) L j Transportation Shipment O by Common Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address ElReinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom }- Remains are Shipped,If Other than Above 2 Address re W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/27/2021 Registrar of Vital Statistics Kimberly WWhefan(Efectronica((y Signed) (signature) District Number 5757 Place Greenwich, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition q iZl+Zi Place of Disposition -�inx 1%--- c—it-oc,..,____ ILI (address) 2 W It (section) (lot number (grave number) o Name of Sexton or Person in Charge of Premises (lease print) r Ili tee/leTitle DOH-1555(07/18)p 1 of 2 ti 0 15I 83 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on :.. ' , 20 Pine View Cemetery Representing the funeral home named on burial,Rermit Official Funeral Directors Reg.or License#