Martin-Winchell, Maliki Mateo 100
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Maliki Mateo Martin-Winchell Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/10/2021 1 Mos. 1 Days War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
LU
p Manner of Death Natural Cause 1=1 Accident El Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Timothy Murphy Coroner
Address
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 349
❑Burial Date Cemetery,Crematory or Facility Name
08/23/2021 Pine View Crematorium
Entombment Address
X❑Cremation Queensbury Town,New York
ElDonation
Removal Date Place Removed
and/or and/or Held
- Hold Address
0
C. Date Point of
Cl) LI Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
2 Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/23/2021 Registrar of Vital Statistics Rg6ertAndrew Curtis(E(ectronica((y Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
'
Z Date of Disposition ,-'>_l,_'l Place of Disposition P5ht, > ,e,W t_ irveiic.0
W 1 (address)
W
N (section) (lot number) (grave number)
CC -j S
O• Name of Sexton or Person in Charge of Premises U�Il"'� � 'Te,
(please print)
Z
W Signature J./�"r Title �j�Glti ��
DOH-1555(o7/18)p t of 2
r115066
Public Health Law Sec. 4145(2b)
Receipt
1i
Ht . , ; i
Human remains of '&livered on , 20
i
1
r
Pine View Cemetery Representing the funeral home named on.burin1 permit
Official Funeral Directors Reg.or License#'/' ,�f' •
A
I