Quinones, Gary M r 1� \
NEW YORK STATE DEPARTMENT OF HEALTH FBurial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Gary M.Quinones Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/13/2022 57 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Kingsbury Town Street Address 1028 Dix Avenue,Kingsbury Town,New York 12839
p Manner of Death II Natural Cause Accident Homicide ESuicide nUndetermined riPending
W Circumstances Investigation
W Medical Certifier Name Title
G Jennifer Stratton MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Kingsbury District Number Register Number
ICity,Town or Village 5762 26
RBurial Date Cemetery,Crematory or Facility Name
12/15/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
i Hold Address
(A
0
Date Point of
U)ElTransportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
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 Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/15/2022 Registrar of Vital Statistics Cynthia Bardin(E(ectronicalrySigned)
(signature)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition /2/7—t'Z`z Place of Disposition -i2 ti:e Cr',.-i.4o r.
W (address,
W
CC (section) (lot nu e (grave number)
o Name of Sexton or Person in Cha of P mis �'�`�f'/1e�✓� ` Pk
Z // (please print)
W Signature 4,/,-, �`t Title 0r�� �
DOH-1555(07/18)p 1 of 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#