Winch, Matthew NEW YORK STATE DEPARTMENT OF HEALTH ft tit lc
Vital Records Section Burial - Transit Permit
Name First M 1 Middle Last Sex
Matthew John Winch Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 14, 2012 44 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death RTI
ELJ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El 1--I Pending
CircumstancesInvestigation
W Medical Certifier Name Title
Paul F. Bachman,
Address
3767 Main Street Warrensburg, NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village c 6 0 1 L-12"7
❑Burial Date Cemetery or Crematory
September 17, 2012 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
Q, and/or Address
Hold
aDate Point of
IL ❑Transportation Shipment
ft by Common Destination
a. Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
Li Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
T' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 / t ) ( 2 Registrar of Vital Statistics LA)CA ,Q W
(signature)
District Number 3 b 0 ) Place 6 Lq,v ''
Us \i\-c, r (\t 7 �Z I(�I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/17/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
CO_
NC (section) 4 , (lot number)' (grave number)
Name of Sexton or Person in Charge f Premises g ust/Lir IAra
(please print)
ill Signature Title Merri a0_.
r--
(over)
DOH-1555 (02/2004)