Kennison Sr, Clarence NEW YORK STATE DEPARTMENT OF HEALTH 4t I 5 J
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clarence D. Kennison Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/19/2011 50 years War or Dates 1981-1982
14 Place of Death Hospital, Institution or
. City, To V •- Street Address
�` ♦ Glens Falls Glens Fails Hospital
Manner o ea h TA atural Cause El Accident 0 Homicide Suicide ri Undetermined ri Pending
W. Circumstances Investigation
ill Medical Certifier Name Title
II James North M D
Address
100 Broad Street Glens falls, N Y 12801
Death Certificate Filed District Number Register Number
City, ToltvirViksisCX Cllans Falls 5A01 138
❑Burial Date Cemetery or Crematory
❑Entombment 03/21/2011 Pine View Cemetery cc-evv%cS il
Address
Cremation Oueensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or
r;; Address
CO
O Date Point of
ti❑Transportation Shipment
al by Common Destination
Carrier
iii!Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Niii Name of Funeral Home Maynard D. Baker Funeral Home 01149
Miii Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;' Address
f
t
• Permission is hereby granted to dispose of the human remains descr'b d a ove in .
gg Date Issued 03/21/2011 Registrar of Vital Statistics � 2
(signature)
District Number 5F01 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tU Date of Disposition 3-ay-20t( Place of Disposition ri n4 v i Ct'e w,Jortuw`
M (address)
ILI
CC (section) (lot number) (grave number)
0 �^ i
O Name of Sexton or Person in Char of Premises t irn�� Sr-v( ?1k
2 n (please prinnt)
11.1 Signature .4 L .�.t Title Crcv 4ury ASs4•
(over)
DOH-1555 (02/2004) •