Winchell, Ross Mary byi
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NEWYORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital.Records
Name First Middle Last Sex
Rose Mary Winchell Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/22/2022 52 Years War or Dates
Place of Death Hospital,la titution or
Z City,Town or Village Glens Falls Street Address 12 Chelsea Way Apt. D, Glens Falls, New York 12801
CI []
Manner of Death NaturalCause [] n Accident I (Homicide [] (
Suicide Undetermined []Pending
1 []Suicide [
Circumstances I 'Investigation
WMedical Certifier Name Title
0 Connie Goedert Coroner
Address
1400 St Route 9, Lake George Town, New York 12845
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 438
EBurial Date Cemetery,Crematory or Facility Name
08/25/2022 Pine View Crematorium
Entombment Address
[]Cremation Queensbury Town,New York
EDonation
CRemoval Date Place Removed
and/or and/or Held
1 Hold Address
0
d Date Point of
t/)[]Transportation
p by Common Shipme it
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
[]Reinterment
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
H Remains are Shipped,If Other than Above
2 Address
tE
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/25/2022 Registrar of Vital Statistics `tlegan Nofin(ECectronicar(ySigned)
(signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition J`� ,j_.- Place of Disposition Pi/kt.) fA� G(�12 v /a ress/
W
CC (sectiortl (lot number/ (gave number)
inName of Sexton or Person in Charge of Premises J�rhtie,/V
(please print/
W
�/ r
Signature Title ��'^^�°
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) r_
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#