Kennedy, Elizabeth Jan 26 1602:39p King Funeral Home 5186422322 p.1
NEW YORK STATE DEPARTMENT OF HEALTH
# 7c
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth J. Kennedy Female
Date of Death Age If Veteran of U.S.Armed Forces,
January 25,2016 73 War or Dates
-- Place of Death Hospital, Institution or
City,Town or Village Granville Street Address Indian River Nursing&Rehab.
- Manner of Death®Natural Cause 0 Accident 0 Homicide ❑Suicide ri Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain MD
Address
100 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Granville 5725 4
El Burial Date Cemetery or Crematory
January 26, 2016 Pineview Crematory
['Entombment Address
®Cremation Queensbury. NY
Date Place Removed
- ❑Removal and/or Held
and/or Address
Hold
Date Point of
f Q Transportation Shipment
- by Common Destination
- Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main St.,Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains escrrbed abo e a= dicated-
Date Issued January 26,2016 Registrar of Vital Statistics •
ignature)
District Number 5725 Place Granville,NY 12832
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
- Date of Disposition I j nig, Place of Disposition i�tUE_. (i tilGfl vs..
(address)
°_` (section) //���� (lot number) (grave number)
j Name of Sexton or Person in Charge f Premises L/)(.3 S14 ;tt
lease print)
Signature .A Title air.,Wit
(over)
DOH-1555(02/2004)