Levin, Dr. Kenneth NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dr. Kenneth D. Levin Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 10, 2011 78 War or Dates
ZPlace of Death Hospital, Institution or
Lu City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death rsrl
Natural Cause 0 Accident Homicide 0 Suicide 0 Undetermined 0 Pending
III Circumstances Investigation
W Medical Certifier Name Title
CI Marvin Davidowitz, MD
Glens falls, NY Address
Death Certificate Filed District Number Register Number
City,RWAN89951gdre Glens falls 5601 5 -2_
0 Burial Date Cemetery or Crematory
October 12, 2011 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z 0 Removal and/or Held
a and/or Address
E Hold Pine View Crematorium
0 Date Point of
0. ❑Transportation Shipment
t/? by Common Destination
Carrier
Disinterment Date Cemetery Address
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 Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
CL Permission is hereby granted to dispose of the human remains described above as ipdicated.
Date Issued/0// 24 if Registrar of Vital Statistics LAD c St. ��c..^-(
(signature)
District Number 5601 Cif Glens falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 00)13111 Place of Disposition i ,nt tAu+a C ctnutorw,�
2 (address)
WrC(1)
(section) (lot numbeir.)- (grave number)
0 Name of Sexton or Pears in Charge Premises Avt-tor3(MAO-
0, (please print)
W SignatureTitle atVr1 KO0-
- .
(over)
DOH-1555 (02/2004)