Winslow, Cassius NEW YORK STATE DEPARTMENT OF HEALTH
'A it 33L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cassius Lee Winslow Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 21, 2014 71 War or Dates
Place of Death Hospital, Institution or
If°` City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri 1--I Pending
CircumstancesInvestigation
Medical Certifier Name Title
l
Jennifer Donavan,
Address
100 Park Street Glens Falls, NY 12801
1 Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 6 0 ( 'Z' 9
❑Burial Date Cemetery or Crematory
May 27, 2014 Pine View Crematory
x1❑
. Entombment
Address
,'®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
.;o-❑ Removal and/or Held
• and/or Address
Hold
Date Point of
`❑Transportation Shipment
by Common Destination
ai Carrier
❑ Disinterment
Date Cemetery Address
" ❑ Reinterment Date Cemetery Address
I = Permit Issued to Registration Number
,; Name of Funeral Home M. B. Kilmer Funeral Home 01079
` Address
82 Broadway, Fort Edward NY 12828
7. Name of Funeral Firm Making Disposition or to Whom
s .r
. Remains are Shipped, If Other than Above
Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 ( a - .( (L Registrar of Vital Statistics .)0.Af-
(signature)
District Number S (C ) Place 6�tl�.S l\ f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/27/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) ,blot nu r) (grave number)
• Name of Sexton or Person in C rge of Premises di f-`. «f*
(please print)
Signature Title f Lcvti11tl1 f
(over)
DOH-1555 (02/2004)