Munger, Brian Scott 7
NEW YORK STATE DEPARTMENT OF H EALTH Burial-Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Brian Scott Munger Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/28/2022 58 Years War or Dates
~ Place of Death Hospital,Institution or
W City,Town or Village Northumberland Town Street Address 16B Leonard Street,Northumberland Town,New York 12831
O Manner of Death Natural Cause Accident Homicide Suicide Undetermined FriPending
{g Circumstances Illnvestigation
W Medical Certifier Name Title
G Eugene Ladue Coroner
Address
31 Woodlawn Ave.,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Northumberland District Number Register Number
,Town or Villaje Cie 4563 5
Burial Date Cemetery,Crematory or Facility Name
03/04/2022 Pine View Crematorium
Entombment Address
Cremation Oueensbury Town,New York
Donation
0ElRe move l Date Place Removed
and/or and/or Held
H Hold Address
W
0
C.' Date Point of
U)aTransportation
G by Common Shipment
Carrier Destination
DDisinterment Date Cemetery Address
El
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 Fals,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
SAddress
cc
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2022 Registrar of Vital Statistics Denise;DAlutplty ortsnrrie Stg>red)
(signature)
District Number 4563 Place Town Of Northumberland
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
WDate of Disposition Place of Disposition
a (address)
w
N Q (section) (lot number/ (grave number)
8 Name of Sexton or Person in Charge of Premises
z /please print)
W Signature Title
DOH1555(07/18)p tot 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#