Sisco, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH ` II (0C
Vital Records Section Burial - Transit Permit
o Name First Middle Last Sex
Kenneth William Sisco Male
Date of Death Age If Veteran of U.S. Armed Forces,
et September 9, 2015 73 War or Dates
Place of Death Hospital, Institution or
F
p City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Robert L. Evans, Dr.
He Address
Three Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls C 60 I L) Lj g--
s 0 Burial Date Cemetery or Crematory
September 14, 2015 Pine View Crematory
❑Entombment Address
- ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
: and/or Address
Hold
Date Point of
_❑Transportation Shipment
by Common Destination
'' Carrier
❑ Disinterment Date Cemetery Address
El Reinterment
.r Date Cemetery Address
Permit Issued to Registration Number
_ Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
w` Address
Permission is hereby granted to dispose of the human remains described above as indicate
Date Issued q ) i t ) 5Registrar of Vital Statistics ,./OCAA Y '
(signature)
District Number ‘_c6 o / Place 6 S' \ , N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ir,� lease print)��
Signature Title (Rzb12-
(over)
',OH-1555 (02/2004)