Anderson, Kenneth 41
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
Name First U Middle Last Sex
f kilne.A LGcCIser. • /injars0.1"1. Mace
Date of DeatO Age If Veteran of U.S. Armed Forces,
/72/ .o 1 I (0 War or Dates
j- Place of Death Hospital, Institution or
lm own or Village 6'6,,,Ls A.26 Street Address Clans , -as klospp;ftiC
0 Manner of Death 'Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undeternnined ❑Pending
IliCircumstances Investigation
tti Medical Certifier Name Title
O. bictf k Po f r,,,,, ,vl/)
Address
A fGr k .3:- 6/li"s ‘tLs
Death Certificate Filed District Number SSG/ Register Number
Zi 7r aim or Village nm /alr9/
❑Burial Date i i Cemetery or Cremtory 1
:ii::: ['Entombmentc)/2-0/2u/i / Ink Viet.J (_ meotev/
Address
:: Er6remation •
Date Place Removed
, ❑Removal and/or Held
and/or Address
�= Hold
to
0 Date Point of
❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to fa/ Registration Number
Name of Funeral Home 6,1, , „al 1-/„ 7 ea 2-7 i.,
Address �I�
�R Rain Si- difigeyA(5 , )17/ /l 19
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tZ
UI
": Permission is her by anted to dispose of the huma6 remai describ d above as i dicate .
Date Issued �,3 l/ Registrar of Vital Statistics
(signature
District Number�6 d/ Place /ems, Q £�f, " /D /
:;;.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Itf Date of Disposition 2-2 S-i( Place of Disposition t i1.#U oa C��F4ec,,,
2 (address)
UI
0
CC (section) 4 _ (lot number) (grave number)
0.
0 Name of Sexton or P rson in Cha a of Premises Ns ti,p41.4 .5tN-dIr
Z please print)
Signature Title Mem7 -0
(over)
•
DOH-1555 (02/2004)