Burr, Kenneth TO rM/N OF QUEE9�5BUP,_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kenneth WaXge BURR Male
Date of Death Age If Veteran of U.S.Armed Forces,
November 11 2003 70 'War or Dates Korean Conflict
Place of Death Hospital,Institution or
City, Glens Falls Street Address 553 Glen St.
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
William Bor2os MD
Address
14 Manor
Death Certificate Filed District Number Register Nu er
City, Glens Falls 5601 . -
Date Cemetery or Crematory
❑Burial November 13 2003 Pin Ti w Crematorium
Address
[Cremation Tn of Queensb NY 12
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home.Inc. 00284
s: Address
68 Main Street P.O.Box 67, Hudson"allso NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Id Address
LL
Permission is hereby granted to dispose of the human remains described above/ayi�dl
Date Issued // /3 0-3 Registrar of Vital Statistics
(signature)
s District Numbet5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition
(address)
(section) (lot number) (grave number)
(In
of Sexton or Person in Charge of Premises
(please print)
Signature Title
DOH-1555(10/89) p. 1 of 2 VS-61
13 2 vv\
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V" ML Vl ie_ CA2L(r7z-y-
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with
and subject to its Rules and Regulations to cremate the remains of:
Kenneth Wayne Burr male
(Name) (Sex)
553 Glen St . G1ens:.;Falls NY 12801
(Street) (City) (State) (Zip Code)
who died on the 11th day of november 2003
at553 Glen St Glens Falls , NY 1 ?Rn
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Kaye Grossman , 553 Glen Sti , Glens Falls , NY 12801
(Name) (Address)
Relationship to the deceased friend
Name of Funeral Home Gea-leten Funerai Hem ne
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no
pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange for the cremation
of the remains and to direct the disposition of the cremated remains, that any
personal possessions have either been removed or may be destroyed, and agree
to protect, defend and save harmless Pine View Crematorium from any and all
claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed;
whether r uch claims or demands are not wholly groundless, false or fraudulent.
-""') 68 Main
St , Hudson Falls, NY 12839
(Witness) (Address)
Z-Z44zC553 Glen St,
Glens Falls, NY 12801
(Signa re of Relative or Legal Rep. and Address)
Signed on this date: 11/13/03