Jensen Jr., Kenneth 3 I
NEW YORK STATE DEPARTMENT OF HEALTH `30
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kenneth J. Jensen Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
04 / 09 / 2017 64 War or Dates 1973-1976
}- Place of Death Hospital, Institution or
Z City, Town or Village Schenectady Street Address 1630 6th Ave.
a Manner of Death®Natural Cause E Accident 0 Homicide E Suicide �Undetermined �Pending
liiCircumstances Investigation
la Medical Certifier Name Title
0 Michael Sikirica MD
Address
50 Broad St, Waterford, NY 12188
Death Certificate Filed District Number , /, Register Number
ber
I L
City,Town or Village Schenectady y 47I
' < OBurial Date Cemetery or Crematory
04 / 13 / 2017 Pine View Crematory
s 0Entombment Address
y' Cremation Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
and/or Address
0
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
<' ; Q Reinterment Date Cemetery Address
<' Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
€ Address
402 Maple Ave., Saratoga Sp., NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
"` Permission is h eby granted to dispose of the human remai s escr'bed ye�ja 'ndicated.
>< Date Issued Registrar of Vital Statistics Uil'l i, , : u1i(Ic:1-iTl(
' (signature)
(.J
District Number C-A.40 / Place Schenectady , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
#-Z.
Ili Date of Disposition 4f//7// r-7
Place of Disposition 2/�e J t 2") G.lL 44�-
(address)
W.
W
CC (section) (lot n5ber) (grave number)
ciName of Sexton or s . C arge of Premises ✓u 1 i�vi v 4-Wl e-
z (please print)
Signature Title C la-,04
(over)
DOH-1555 (02/2004)