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Brzozowski, Dylan C. V. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dylan C.V.Brzozowski Male Date of Death Age If Veteran of U.S.Armed Forces, 03/10/2023 42 Years War or Dates 1, Place of Death Hospital,Institution or Z City,Town or Village Chester Town Warren Street Address 4706 State Route 8,Chester Town Warren,New York 12817 LU `p Manner of Death El Natural Cause ❑Accident El Homicide Suicide DUndetermined ElPending Circumstances Investigation W Medical Certifier Name Title G Lynn Keil Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Chester District Number Register Number City,Town or Village 5652 2 Burial Date Cemetery,Crematory or Facility Name 03/17/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York DDonation g❑Removal Date Place Removed and/or and/or Held Hold Address CO 0 a Date Point of tl1❑Transportation a by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC CiJ a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/13/2023 Registrar of Vital Statistics Minty Conway(`ECectronicaffy Signed) (signature) District Number 5652 Place Town Of Chester I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 31 n RI Place of Disposition �/," (2tbra.--- 2 (address) W CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pre . es °' �-- Z (plettse print) W Signature Title 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 Ret.or License#