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Kendrick, Joseph NEW YORK STATE DEPARTMENT OF HEALTH I\ Vital Records Section 4kt Burial - Transit Permit Name First 1 Middle Last Sex 0- ' -y'// p K A)D/Z-/ e% /iA-Lt- Date of Death Age If Veteran of U.S. Armed Forces, aC j If Z 00,6 77 War or Dates / jy Z 4 xO1z--A 14 Place of Death Hospital, Institution or Gity, -et-Village LA/t /°L�t-C�ptil Street Address U//�L�/N 1L26 zcy C -i</TEJZ 3 Manner of Death©Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending U Circumstances Investigation W Medical Certifier Name Title hoc / be 74 .LID Address UllftCJii /-4c—nay CTJt L-Ake "44.el, Death Certificate Filed District Number Register Number City, Town or Village Ley/LE %L,41,'e ISO, ['Burial Date Cemetery or Crematory EntombmentO C.I /0 20 o 6 P,I/, i//-4✓ e_1z-6-A7,4 Tdlny Address MCremation L L_Etis PAt cf /v/ Date Place Removed 1-1 Removal and/or Held ...� and/or Address t Hold N 0 Date Point of d Transportation 0- Shipment G by Common Destination Carrier Disinterment Date Cemetery Address „1 Reinterment Date Cemetery Address Permit Issued to Registration Number 4i1.ii. Quark.Jnc. Name of Funeral Home 0 f l i-1‘ 2310 Saranac Ave. Address Lake Placid, NY 12946 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address W 0` Permission is hereby granted to dispose of the human remains described above afrigklicated. Date Issued /d1172Q 6' Registrar of Vital Statistics ' c�� oC . Jam, (signature) District Number l36-0 Place GAkL /'L,4 C'/p A/vyL7/! /3.0 tip/ 1-=• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W. Date of Disposition I o i 40/0- Place of Disposition Pok,,,,t w CrI"IN cC o n tirt 2 (address) Illt 'CO CC (section) (lot number) (grave number) ci Name of Sexton or Person Charge of Premises Ci P s ,n n it (please print) Ltl SignatureL Title G��-zi,,c (over) DOH-1555 (02/2004)