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Culver, Dylan Edward -105 WO NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dylan Edward Culver Male Date of Death Age If Veteran of U.S.Armed Forces, 09/23/2023 24 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Village Street Address 2 Brightwood Street,Fort Edward Village, New York 12828 W 'p Manner of Death �NaturalCause nAccident Homicide nSuicide nUndetermined []Pending U ' 'Circumstances I 'Investigation W Medical Certifier Name Title CI Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 82 Burial Date Cemetery,Crematory or Facility Name 09/26/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held Hold Address CO 0 d Date Point of N 1-Transportation p by Common Shipment Carrier Destination nDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped,If Other than Above Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/26/2023 Registrar of Vital Statistics .inaeeL2laIioney('6lctrorrically4ned) (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: I- Z Date of Disposition 9 1/3 Place of Disposition nrnA,v C P641 at T.V/Fitn W 2 (address) W CC N (section) Al/ (lot numb (grave number) 0 Name of Sexton or Person in Charge of re ises `/ `ihpi' Z lease print)W e,Signature Title IA p DOH-1555(07/18)p 1 of 2 • -T Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery rf Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#