Measeck, Kenneth t
t NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kenneth Lawrence Measeck Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 25, 2015 90 War or Dates World War II
Place of Death Hospital, Institution or
Lit City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause 0 Accident El Homicide 0 Suicide ElUndetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Marvin Davidowitz, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Numbe � l Register �er
City, Town or Village
®Burial Date Cemetery or Crematory
April 27, 2015 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Rd. Queensbury,NY 12804
- Date Place Removed
z � Removal and/or Held
and/or Address
_; Hold Pine View Cemetery
9! Date Point of
, Transportation Shipment
W by Common Destination
0 Carrier
0 Disinterment
Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Fural Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
#iai
Permission is hereby granted to dispose of the human rem 'ns descr' ed above s indicate .
Date Issued Q / Registrar of Vital Statistics LA____,
(signature)
District Number S�j l Place 6/,7f faf1/._$ /t/- /al
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
▪ Date of Disposition 04/27/2015 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
W 7C Mohican 1
r (section) (lot number) (grave number)
Name of Se n or Person in Charge of Premises Connie L. Goedert
(please print)
W Signatur _Zi L-f `- j G --- Title Cemetery Superintendent
(over)
•
DOH-1555 (02/2004)