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O'Sick, Mary li*. 74 Li --) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mark O'Sick Male Date of Death Age If Veteran of U.S.Armed Forces, 06/11/2023 52 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address 67 Perkins Drive, Fort Edward Town, New York 12839 iw Manner of Death g � �NaturalCause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation WI Medical Certifier Name Title CI Charles Yun MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 53 Burial Date Cemetery,Crematory or Facility Name 06/12/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York DDonation 0❑Removal Date Place Removed and/or and/or Held F- Hold Address N 0 G. Date Point of Cl)❑Transportation p by Common Shipment Carrier Destination O Disinterment Date Cemetery Address El 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 F— Remains are Shipped,If Other than Above 5 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/12/2023 Registrar of Vital Statistics Cynthia Bardin(ECectronical(ySigned) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition 1l�173 Place of Disposition S,,,.�/_, ,,,,�d---- lJJ (a dress) W CCCC (section) A (lot number) (grave number) 0 Name of Sexton or Person in C2oPremi ses '`"'it Z (lease print) �7 W Signature Title �� DOH-1555(07/18)p 1 of 2 7 1)?6 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#