Kennedy, William / 1 p
NEW YORK STATE DEPARTMENT OF HEALTH o f
Vital Records Section E Bu
rial rial - Transit Permit
f " Name First Middle Last Sex
William Joseph Kennedy Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 14, 2016 91 War or Dates World War II
Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 85 Mohican St.
Manner of Death n Natural Cause n Accident n Homicide n Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Doug Dennett,MD
Address
84 Broad Street,Glens Falls,NY 12801
f ` Death Certificate Filed District Number Register Number
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,..A.; City, Town or Village Village Of Lake George 5620
❑Burial Date Cemetery or Crematory
November 16, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
u) Transportation Shipment
'p by Common Destination
Carrier
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Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
p Permit Issued to Registration Number
'' Name of Funeral Home Regan Denny Stafford Funeral Home 01443
0f; Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
V. Remains are Shipped, If Other than Above
"Address
Permission is hereby granted to dispose of the human remains described above as indicated.
1
Date Issued 1 i I 1 b(WIG Registrar of Vital Statistics 69 piar cc ek,vm l'
FrY+ l
(signature)0District Number 5620 Place Village Of Lake George
M.
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition i t'/'7//c, Place of Disposition V , Q.LJh�"+'Q�) I�'1 r�
W (address)
N
W (section) , (lot number) 1 (grave number)
in Name of Sexton or Person in Charge 16f Premises Go" LA) )>0.�. I c,r c. e—
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(please print)
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Signature �, / �� J Title C�yus.w.�,"1'A l
C/
(over)
DOH-1555(02/2004)