Keefer, Kenneth NEW YORR STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
r Name First Middle Last Sex
:rf: Kenneth G. Keefer Male
▪ Date of Death Age If Veteran of U.S. Armed Forces,
:'a July 5, 2014 89 War or Dates Navy
iPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines Of Glens Falls
Manner of Death
X Natural Cause n Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
E:iF'
Bernardo Villajuan,MD Address
;;r 161 Carey Rd.,Queensbury,NY 12804
:: Death Certificate Filed Glens Falls,NY District Number RegisNumber
'•�• City, Town or Village 5601
❑x Burial Date Cemetery or Crematory
July 8, 2014 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, , NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
H Hold
N
o Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
;:r, Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
.::▪ i Address
53 Quaker Road,Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
g
gi
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 GO j Registrar of Vital Statistics (OJJ *f A
I: : (signature)
District Number 5601 Place Glens Falls,NY
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7/8/1 4 Place of Disposition Pine View Cemetery
2 (address)
W CD New Kenesaw 7A 1
O (section) (lot number) (grave number)
pName of Se n or Person in Charge of Premises Connie Goedert
w Super iAPteg8r4rit
Signature L,41-1L, Title
e
(over)
DOH-1555(02/2004)