Kirsihenbaum, Benjamin NEW YDRK STATE DEPARTMENT DFHEALTH ��NN�~��U ~ ~N~�^�����~� Q�^��0��^�
Vital Records Section
��=~= "�~� Transit Permit
Name First Middle Last Sox
Date of Death
Age If Veteran of U.S.Armed Forces,
War or Dates
..z. Place of Death Hospital, Institution or
:..W City,Town or Village City of Glens Fa 1 ls Street Address Glens Falls Hospital
A Manner of Death Natural Cause Accident Ej Homicide El Suicide
Undetermined E] Pending
JLU Circumstances Investigation
Medical Certifier Name Title
113__-_`______-James'__������__ ___ ------------_-
Death Certificate Filed District Number Register Number
City of Glens Falls 5601
City,Town or Village
Date Cemetery or Crematory
Cremation Address
0 Removal and/or Held
ddress
Cn
CL Date Point of
Ln, [:]Transportation by Shipment
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Sullivan Minahan and Potter Funeral Home 01933
67 Park St. Glens Falls, New York 12801
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Permission is hereby granted to dispose of the huma m;alns escrib abo�vea indicated.
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Date Issued I0-22-90 Registrar of Vital Statistics
District Number 5h01 p|ouo City of Glens Falls New Yorkl2801
A�
� |ooudy that the remai0s ofth7PIace
identified d n1abovew ou with
on:
Date ofDiapood�n ufDiopoo��n �� /*-
^ /
/( ~cc
(section) � / (lot number)' ' (grave number)
!� ! \ \ (please print
Signature Th|o .�
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