Mulholland, Kenneth V 4 . , # 16O
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
igi Name First Middle Last Sex
Kenneth Leonard Mulholland Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/24/2011 58 years War or Dates
14 Place of Death Hospital, Institution or
X City, To i Street Address
XX Glens Falls Glens Falls Hospital ,
a Manner o eath❑(Natural Cause 0 Accident Homicide Suicide Undetermined Pending
W. Circumstances Investigation
ut Medical Certifier Name Title
0 Michael Adams M R
Address
1448 Route 9, South Glens Falls, NY 12803
Death Certificate Filed District Number Register Number
City, Towim /ilx Glens Falls 5601 142
❑Burial Date Cemetery or Crematory
❑Entombment 03/25/2011 Pine View Crematorium
Address
ii i OCjemation Oueensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or
�; Address
CA
Hold
0 Date Point of
tL Transportation❑ p Shipment
by Common Destination .
giiii Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01149
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom •
Remains are Shipped, If Other than Above
E Address
tr
to
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/25/2011 Registrar of Vital Statistics ' k.. • �" '
(sign er )
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
LU Date of Disposition 3-1 S-i I Place of Disposition Plea IL14 Crvc for ivy
(address)
In
CO
CC (section) (lot nu r) (grave number)
0
Ci Name of Sexton or Person in Charge f Premises ,,s t.• f� �ua
(please print)
ro SignatureavL Title (1 )tfF I—
(over)
DOH-1555 (02/2004)