Pinkowski, Michael Walter s # gZ3
NEWAORK STATE DEPARTMENT OFHEALTH - � Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Walter Pinkowski Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/12/2022 66 Years War or Dates
E,., Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p• Manner of Death C Natural Cause []Accident n Homicide []Suicide Undetermined []Pending
W Circumstances ' 'Investigation
U
W Medical Certifier Name Title
CI Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 526
[]Burial Date Cemetery,Crematory or Facility Name
10/17/2022 Pine View Crematorium
[]Entombment Address
Cremation Queensbury Town,New York
CDonation
O[]Removal Date Place Removed
and/or and/or Held
F— Hold Address
N
0
tl Date ' Point of
(/)[]Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
[]Disinterment
C Reiuterment
Date Cemetery Address
Permit hssued 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
Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/17/2022 Registrar of Vital Statistics llegan Wolin(Electronically Signed)
(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: y
Z Date of Disposition /0'Win, Place of Di!position u.V t' i—r r,—_
2 (address)
W
CC (section) (lot number) C.-- (grave number)
0 it
Name of Sexton or Person in Charge of Premises ��`�' ('` ��"'`�
111
/ (ple4se print)
Z
W Signature Title rekmsi1
DOH-1555(07/18)p 1 of 2
I
.
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#