Winters, Brian O
NEW YORK STATE DEPARTMENT OF HEALTH ' ' s lik'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Brian Dirk Winters Male
s i Date of Death Age If Veteran of U.S. Armed Forces,
,,; - August 8, 2015 52 War or Dates
t Place of Death Hospital, Institution or
ai City, Town or Village Jackson Street Address 10 Winters Way
i Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
.lJ` Circumstances ❑ Investigation
W Medical Certifier Name Title
0 Matthew Pender, M.D.
Address
131 Lawrence Street Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Nber
▪ City, Town or Village
❑Burial Date Cemetery or Crematory
August 11, 2015 Pine View Crematorium
yt ❑Entombment Address
Tg®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F Hold
Date Point of
❑p Transportation Shipment
CO by Common Destination
c Carrier
Date Cemetery Address
El Disinterment
4M
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
` . Address
IX
aJi
Permission is hereby granted to dispose of the hums mainns�describ ab ye a ft"' ed.
Date Issued g—I I—15 Registrar of Vital Statisti9 �i�',v! Ka"— Ili,'
�/e (sign )
District Number�7a/ Place ecijQ Vi �l.) , (/�'�v u_-,C4 /n '
. y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uj Date of Disposition 08/11/2015 Place of Disposition Quaker Road Queensbury,NY 12804
5 (address)
ir (section) / lot number) (grave number)
d' Name of Sexton or Person in Charge of Premises l ^'+�� SE"�rhf'
Z'; (phSe print)
W Signature /�— Title of
(over)
DOH-1555 (02/2004)