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Etu, Wiliam Joseph 111 It`i12 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William Joseph Etu III Male Date of Death Age If Veteran of U.S.Armed Forces, 12/04/2023 80 Years War or Dates 1— Place of Death Hospital,Institution or Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing p▪ Manner of Death El Natural Cause Accident El Homicide OSuicide FlUndetermined Pending W Circumstances Investigation C) Title Ili Medical Certifier Name G Joshua Starteri NP Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed Town Of Granville District Number Register Number City,Town or Village 5756 71 ElBurial Date Cemetery,Crematory or Facility Name 12/06/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held t— Hold Address CO 0 Date Point of U)❑Transportation Shipment p by Common Carrier Destination o Date Cemetery Address Disinterment • Date Cemetery Address EiReinterment 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 N Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/06/2023 Registrar of Vital Statistics Jenny Linda M Martelle(Electronically Signed) (signature/ District Number 5756 Place Town Of Granville I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1— Z▪ Date of Disposition I2-I la 113 Place of Disposition 'C �.NC-✓.1-CJ �(Pi1 417f✓T � • 2 (address) W Cl)CC (section) (*Arill tl (lot number) ^ (grave number) it 0Name of Sexton or Person in Charge of P emises \-_i Zllease print) W Signature Title 46)'4 1.-k DOH-1555(07/18)p 1 of 2 #asuaaq Jo -2OJ szopaUQ tunun3 intaUJO puuad ieunq uo pauzuu auioq im unj aqa 2upuasaida21 AialauuaD Min au!d r t� r oZ ° uo ponAljap Jo suTMJ utuznH ! ldtaaag • (gZ)S17it 'aas "fl 'moll aijgnd