Kenney Jr, Paul NEW YORK STATE DEPARTMENT OF HEALTH, Q
4 Pf8
Vital Records Section Burial - Transit Permit
Name rst Middle ast ex
Date of DeathAge If Veteran of U.S. Armed Forces\
7 'Z L1//L 3 I War or Dates ti .,
I- Place of Death kt„c„ t dcc,k Hospital, Institution or �‘k,- V`�L- -t-CC',CC�A
City, Town or Village C sly\eO \\y Street Address t -1}� Q
W Manner of Death Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
ill Medical Certifier Name Title
0 H i e . am` r\SS I (`-11
Adclress
Death Certificate Filed District Number. Regsstbr Number
City, Town or Village ` �v.J0`\ to + 15 a.
❑Burial Date iii
Ce ery or Crematpry
J( \KE \ ,e�,J C (L rti1cL. 0 -L
DEntombment Address
KCremation QO e e c\Sb((y, iQsq
Date Place Removed
Z ri❑Removal and/or Held
and/or Address
N Hold
tl)
0 Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home '\\ (C)X 0 y),.\ \-1, c Z 1
Address
1 I N ai� (_)) \� `S A \ \C�ic\s, Cnc:, y 1 7_ Fs 3
Name of Funeral Firm Making Di position or to Whom
Remains are Shipped, If Other than Above
2 Address
it
lI
cL
Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued 7/Zip/A,(a Registrar of Vital Statistics �` �-� C�,V_,t;' 1�—
C signet e)
District Number t Place c k �
l
I certifythat the remains of the decedent identified move were disposed of in acc2�tdance with this permit on:
�
LEI Date of Disposition II si(b Place of Disposition f O�,,/ C' ^
it ^-
2 (address)
1i1
Mt
Cc (section) -�/ (lot number) (grave number)
pName of Sexton or Person in Charge of Premises G� I �Ennrll"
Z. (please print)
Signature W` Title (M'kik,
(over)
DOH-1555 (02/2004)