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Funk, Joesph Michael gl NEWYORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Joseph Michael Funk Male Date of Death Age If Veteran of U.S.Armed Forces, 10/14/2023 64 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Forestport Town Street Address Nichols Mills Road, Forestport Town, New York 13338 p Manner of Death Natural Cause Accident ElHomicide OSuicide Undetermined ❑Pending W U Circumstances Investigation LU Medical Certifier Name Title Dianne Vertes MD Address 100 Elizabeth Blackwell Street,Syracuse,New York 13210 Death Certificate Filed Town Of Forestport District Number Register Number City,Town or Village 3259 10 Burial Date Cemetery,Crematory or Facility Name 10/23/2023 Pine View Crematory IllEntombment Address ©Cremation Queensbury Town,New York Donation ZZ❑Removal Date Place Removed _ and/or and/or Held N Hold Address 0 Date Point of U)❑Transportation p by Common Shipment Carrier Destination Disinterment 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 l— Remains are Shipped,If Other than Above g Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/20/2023 Registrar of Vital Statistics Tracy Tarty gYectronica6Signen9 (signature) District Number 3259 Place Town Of Forestport I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: l— W Date of Disposition Mk, Place of Disposition {''7' J' CI&I \IVeZAM- 2 (address) W CC N (section) // (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises �.... c D+►.1 (p ase print) W Signature Title fie16'✓ Tri DOH-1555(07/18)p t of 2 017398 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named op burial permit Official Funeral Directors Reg.or License#