Russell, Kenneth % I W
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kenneth C. Russell Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 29,2018 59 War or Dates
F Place of Death Hospital, Institution or
Z: City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death .X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Michael Sikirica
Address
50 Broad St.,Waterford,NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 7
❑Burial Date Cemetery or Crematory
December 4,2018 Pine View Crematory
Entombment
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
O Date Point of
co Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
M Remains are Shipped, If Other than Above
• Address
rt
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t 4 / I Registrar of Vital Statistics -'v-
(sig ture)
District Number 5601 Place Glens Falls)N y?
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 12/S jI$ Place of Disposition f, , p--
(address)"
W
U)
(section) (lot numb (grave number)
Q Name of Sexton or Perso in Charg of Premises 11/44v e.4111
Z (plse print)
w Signature Title Ce"41141
(over)
DOH-1555 (02/2004)