Winchell, Robert Harvey LF -z
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert Harvey Winchell Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/03/2022 76 Years War or Dates 1965-69
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 33 Tuthill Road,Queensbury Town,New York 12804
p Manner of Death ❑X Natural Cause []Accident El Homicide DSuicide FlUndetermined ❑Pending
W Circumstances Investigation
U /
W Medical Certifier Name Title
Melanie Duerr NP
Address
47 Tom Phelps Lane,Mineville Hamlet,New York 12996
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 65
Burial Date Cemetery,Crematory or Facility Name
04/05/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
H
N Hold Address
0
O. Date Point of
N Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/05/2022 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
Z Date of Disposition (ZZ Place of Disposition 2ess)
n,� t�—
W
N (section) 41,1.44
(lot number) (grave number)
CName of Sexton or Person in Charge of Premises l'_' �tZ L--./' ' ease print)
W Itr -
Signature y Title
�PT M�
DOH-1555(07/18)p 1 of 2
i
15 �
Public Health Law Sec. 4145(2b)
i
Receipt
Human remains of delivered on , 20
I
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#