Secor, Jr. Kenneth NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kenneth L. Secor,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 29,2011 80 War or Dates Korean
Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street Address 3733 State Route 8
d Manner of Death I XI Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
w; Medical Certifier Name Title
John E.Lukaszewicz
Address
84 Broad St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 7
❑Burial Date Cemetery or Crematory
January 31,2011 Pine View Crematory
111 Entombment Address
[R Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
9. and/or Address
▪ Hold
O Date Point of
N Transportation Shipment
p 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 00035
Address
3809 Main Street,Warrensburg,NY 12885
• Name of Funeral Firm Making Disposition or to Whom
!- Remains are Shipped, If Other than Above
2] Address
°Lt}<
Permission is hereby granted to dispose of the human rem ins described abas indicated.
Date Issued I— 3 aO tl Registrar of Vital Statistics'
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition {Ea, Z Zot( Place of Disposition 'Fine JIAA/ Cry 4 sr IN1
(address)
U)
(section) (lot numb (grave number)
Z Name of Sexton or P rson in Char/ of Premises �rN�lf-
f (please print)
W
Signature 4 Title CUIcMTot.
(over)
DOH-1555 (02/2004)