Kilburn, Winston , . 4 CIO
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section urial - Transit Permit
Name First Middle st Sex
Winston Spencer Kilburn Male
Date of Death Age If Veteran of . . Armed Forces,
06/07/2018 74 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death IT Natural Cause Accident Ei Homicide Suicide ElUndetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Enrico Bravo MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed f District Nuttier Register Number
City, Town or Village Saratoga Springs 4501 321
❑Burial Date Cemetery or Crematory
06/11/2018 Pine View Crematory
,❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment
Date Cemetery Address
{ Reinterment Date Cemetery Address
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
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/08/2018 Registrar of Vital Statistics John PPranck(ECectronica((ySigned)
ti (signature)
_ District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 4 lit lig Place of Disposition ?NC./
(address)
( (section) /• (lot number)r (grave number)
Name of Sexton or Person in Charge of remises 1'^i JD
( se print)
Signature Title in01 1/
(over)
DOH-1555 (02/2004)