Klein, Kenneth t(5o
NEW YORK STATE DEPARTMENT OF HEALTH t 1
Vital Records Section Burial - Transit Permit
f Name First Middle Last Sex
Kenneth Edward Klein Male
irr
w Date of Death Age If Veteran of U.S. Armed Forces,
y;r September 4,2015 70 War or Dates
'' Place of Death Hospital, Institution or
City, Town or Village Lake Luzerne Street Address Route 9N
Manner of Death
Lim
Medical Certifier
Natural Cause Accident Homicide n Suicide Undetermined Pending
Circumstances Investigation
Name Title
; " Michael Sikirica,MD
Address
50 Broad Street,Waterford,NY 12188
I Death Certificate Filed District Numher-�� ) um Register Number
'A; City, Town or Village ��..vv
❑Burial Date Cemetery or Crematory
September 8,2015 Pine View Crematorium
❑Entombment - Address
El Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r
r.:r.r..
Permit Issued to Registration Number
,;,, Name of Funeral Home Regan Denny Stafford Funeral Home 01443
1, Address
0 53 Quaker Road,Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ins desc i d bove as indicated.
tea__ .
Date Issued el 4- s Registrar of Vital Statistic [t✓,6 �rL�,
(signature) /
District Number 5(P5(4. Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tu Date of Disposition '7/ioj(3 Place of Disposition geo r* pt►•-^'
(address)
W
N
CL (section) (lot numbe (grave number)
pName of Sexton or Person in Ch rge of Premises ,
Z6 please print)
IliSignature Title bL
(over)
DOH-1555(02/2004)