Etu, Michael Joseph di
0LFf NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Joseph Etu Male
" Date of Death Age If Veteran of U.S.Armed Forces,
, 03/30/2022 66 Years War or Dates
Place of Death Hospital,Institution or
W, City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
ra Manner of Death []Natural Cause []Accident []Homicide []Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Joshua Started NP
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed Town Of Argyle District Number Register Number
City,Town or Village 5750 12
[]Burial Date Cemetery,Crematory or Facility Name
04/04/2022 Pine View Crematory
[]Entombment Address
aCremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held __
N
Hold Address
0
t1 Date Point of
0❑Transportation Shipment
Q by Common
Carrier Destination
[]Disinterment Date Cemetery Address
Date Cemetery Address
■Reinterment
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
$ Address
CC
ir
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/04/2022 Registrar of Vital Statistics Shelley 9Kckernon(E(ectronicaCCySigned)
(signature)
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: .,
Z▪ Date of Disposition 14i2Z. Place of Disposition �'/y.clL„
2 (address)
Ili
CO
ft (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of r ises ���' N At II
/T ease print)
/N
Ili Signature Title l� r'"�1(4
DOH-1555(07/18)p t of 2
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Public Health Law Sec. 4145(2b)
1 Receipt
Human remains of delivered on , 20
[ Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#