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Breunig, Brian # -o-) NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Brian Breunig Male Date of Death Age If Veteran of U.S.Armed Forces, 05/22/2023 66 Years War or Dates i.. Place of Death Hospital,Institution or Z City,Town or Village Bolton Town Street Address 420 Coolidge Hill Road, Bolton Town, New York 12824 IJJ p Manner of Death Z Natural Cause Accident Homicide Suicide FiLlndetermined ElPending W Circumstances Investigation W Medical Certifier Name Title CI Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Bolton District Number Register Number City,Town or Village 5650 7 Burial Date Cemetery,Crematory or Facility Name ® 05/23/2023 Pine View Crematorium Entombment _ Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held H Hold Address CO 0 a Date Point of Cl)ElTransportation Shipment p by Common 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 H 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 05/22/2023 Registrar of Vital Statistics Jodi rPetteys(ECectrronica1tySigned) (s)gnature/ District Number 5650 Place Town Of Bolton I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- ,�/' Z Date of Disposition .�/Z:S 17-3 Place of Disposition e Zi.k 111 ti 2 (address) W NCC (section) 4 (lot number) (grave number) :51,4 Name of Sexton or Person in Charge of Premises '` L. ftr.Z (p ease print) la �� Title rp jZ f Signature DOH-1555(018)p i of 2 Public Health Law Sec. 4145(2b) 0169 6 Receipt Human remains of delivered on N' Pine View Cemetery Representing the funeral home named oq burial,,permit Official Funeral Directors Reg.or License# •''