Siverling, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First - - Middle Last Sex
Kenneth A -Siverling male
Date of Death Age If Veteran of U.S. Armed Forces,
0 2/0 4/2 011 77 War or Dates • WW II Army
.}- Place of Death • Hospital, Institution or .
u City, Town or Village South Glens Falls Street Address 16 Iris Rd
W Manner of Death 0 Natural Cause D Accident Homicide 0 Suicide 0 Undetermined Pending
Circumstances Investigation
iii Medical Certifier Name Title
P. T . Coppens M1)
Address
Irongate Center Glens Falls NY
Death Certificate Filed District Number Register Number
City, Town or Village South Glens Falls •
0Burial Date Cemetery or Crematory
02/08/2011 Pine View Crematory
Entombment Address
. ;;;;;_ Cremation Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
1 and/or/or Address
fa
0 Date Point of
IN0 Transportation Shipment
CS by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
s> Name of Funeral Home Regan And Denny 01465
Address
94 Saratoga Ave South Glens Falls NY
Name of Funeral Firm Making Disposition or to Whom
}I Remains are Shipped, If Other than Above
•
Address
tr
E
` Permission is hereby granted to dispose of the human remains described above as indicated.
Ai
Date Issued v? `A -�� Registrar of Vital Statistics d4.4,e
z'a
(signature)
District Number
/SSG,• Place % Jf�'L,e
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z '`
La Date of Disposition � 6)t 1 \ Place of Disposition Pi nr V yt t,/ Cem-ctdrItin:
(address)
iii
til
ir (section) / (lot number) (grave number)
ci Name of Sexton or Per in Charge of • mises l n skAt r' �.h-df
(please print)
Signature "fr Title CriC:11 F 0V
(over)
•
DOH-1555 (02/2004)