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Dickinson, Brian#qI N EW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Brian Lee Dickinson Male Date of Death Age If Veteran of U.S. Armed Forces, 10/05/2019 60 Years War or Dates Place of Death Hospital, Institution or WCity, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing Q W Manner of Death © Natural Cause Accident Homicide Suicide Undetermined Pending V Circumstances Investigation Medical Certifier Name Title QW Roslyn Socolof MD Address 42 Gurney Ln, Queensbury Town, New York 12804 Death Certificate Filed District Number Register Number City, Town or Village Queensbury 5657 147 ❑ Burial Date Cemetery, Crematory or Facility Name Entombment 10/15/2019 Pine View Crematorium FKCremation Address Queensbury Town, New York Donation OZ 0 Removal Date Place Removed and/or and/or Held Hold Address O d Cl) ❑ Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Stpo Box 67, Hudson Falls, New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address cc W (' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/08/2019 Registrar of Vital Statistics Caroline MiCdegardeBar6er(ECectronicaCCySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H e-'?`^ Date of Disposition Pirl I Place of Disposition W,w rw��(/r;J— tZL g (address) W N cc /sedion/ ] llot number/ ` (grave number/ �AP� O Q Name of Sexton or Person in Charge of Premises �r ✓P,n+t'( Z /ease print/ W / Signature l✓' 4 Title (UP DOH-1555 (07/18) U 1 of 2 PUBLIC HEALTH LAW § 4145• Deaths; burial and removal permits; disposition of remains. 1. No person in charge of any premises on which interments, cremations or other disposition of the body of a deceased person are made shall inter or permit the interment or other disposition of any body unless it is accompanied by a burial, cremation or transit permit, as provided in this article. 2. (a) The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition before interring or otherwise disposing of the body or shall attach the removal or transit permit to the box containing the body, when shipped by any transportation company, which permit shall accompany the remains to its destination, where, if within this state, it shall be delivered to the person in charge of the place of burial or other disposition. (b) Any person or other entity owning, operating, managing, or designated to receive the body of a deceased person at a place of burial, cremation, or other final disposition in this state, who receives the body of a deceased person, shall provide a receipt for the body to the funeral director, undertaker or registered resident who delivered such body. Each receipt shall (i) be endorsed by both such person and the funeral director, undertaker or registered resident, (ii) indicate the date the body was delivered, (iii) include the name of the funeral director, undertaker or registered resident delivering the body and the registration number of such funeral director, undertaker or registered resident, (iv) include the name of the registered funeral firm the funeral director, undertaker or registered resident represents, (v) include the name of the deceased person as it appears on the burial, cremation, or transit permit, and (vi) include the name of the owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition who received the body of the deceased person. A copy of such receipt shall be retained by the owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition for a period of not less than four years, and shall be made available for inspection by the division of cemeteries during normal business hours. The original copy of every such receipt shall be retained by the licensed funeral firm for a period of not less than four years pursuant to the rules and regulations of the department governing the maintenance of records. 3. The person in charge of the place of burial or other disposition shall endorse upon the permit, the date of interment, or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of interment, cremation or other disposition. 4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge, the funeral director or undertaker shall (a) sign the burial or removal permit, giving the date of burial; (b) write across the face of the permit the words "No person in charge; " and (c) file the burial or removal permit within three days with the registrar of the district in which the cemetery is located. 5. The person in charge of the place of burial, cremation, or other disposition shall keep a record of all bodies interred or otherwise disposed of on the premises under his charge, in each case stating the name of each deceased person, place of death, date of burial or disposal, and name and address of the funeral director or undertaker, which record shall at all time be open to official inspection. DOH-1555 (07/18) p 2 of 2 1. .. t Public Health Law Sec. 4145(2b) Receipt 013006 Human remains of delivered on 20— Pine View Cemetery Relvesenting the funeral home named on burial, permit Official Funeral Directors Reg. or License #