O'Neil, Kevin NEW YORK STATE DEPARTMENT OF HEALTH Ir
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kevin A. O'Neil Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 1,2015 62 War or Dates
i,., Place of Death Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address Moses Ludington Hospital
' Manner of Death I XI Natural Cause I I Accident t I Homicide Suicide I Undetermined Pending
W Circumstances Investigation
itk Medical Certifier Name
Title
CI Todd Waldorf
Address
HHHN,Ticonderoga,NY 12883
Death Certificate Filed District Number Regi a r Number
a City, Town or Village j CG� /e
ID Burial Date Cemetery or Crematory C9
❑Entombment December 3, 2015 Pine View Crematory
Address
CI Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z [ I Removal and/or Held
and/or Address
I- Hold
O Date Point of
U)i I Transportation Shipment
L'f 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 00037
' Address
.% 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tt
Q Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1a/3/ 5 Registrar of Vital Statistics 4) in • ( f:e--(-----
(signature)
_ District Number 1 5 Lo+ Place �, h
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w2 `•n e Date of Disposition ).)-4- ,3 Place of Disposition i e,-..1 Ci'e,4 l car.``a m
(address)
III
o (section (lot number) (grave number)
ZName of Sexton or Person in Char e of Premises ( c Al u ( y 1J�ur!e/(p
Z (please print)
LLISignature~ ,�,�,,,�,;:6 Z..14.4„
Title C rewt a:.+o it A SS4
(over)
DOH-1555 (02/2004)