Courts, Kenen 4 gcL
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section r
Name First Middle Last Sex
KENEN COURTS MALE
-- Date of Death Age If Veteran of U.S.Armed Forces,
4.4 9/17/12 ', 40 War or Dates NO
Place of Death Hospital, Institution
City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
t.-34 Manner of Death Natural Undetermined Pending
® Cause El Accident ❑ Homicide El Suicide ❑ Circumstances ❑ Investigation
Medical Certifier Name Title
JOHN KEEGAN CORONER
Address
112 STATE ST. ALBANY, NY (a,26�
Death Certificate Filed District Number Register Number
I City,Town or Village City of Albany 101 1784
❑ Burial Date Cemetery or Crematory
❑ Buombment 9/20/12 PINE VIEW CREMATORIUM
® Cremation Address
QUEENSBURY, NY (?- 4
Date Place Removed
2, ❑ Removal and/or Held
C. and/or Address
1,,". Hold
0 Date Point of
CL Transportation Shipment
U) ❑ By Common
CI Carrier Destination
El Disinterment Date Cemetery Address
IDDate Cemetery Address
Reinterment
Permit Issued To Registration Number
¢; Name of Funeral Home BARTON-MCDERMOTT FUNERAL HOMWE, INC. 00141
A Address
1 9 PINE STREET CHESTERTOWN, NY 12817
--,_z, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
0-141 Permission is hereby granted to dispose of the human remain cribed above as indicated.
Date 9/20/12 Registrar of Vital Statistics s"��,'V' l-,d
Issued g (signature)
6,-
District Number 101 Place City of Albany, NY 1420$
I certify that the remains of the decedent identified above were disposed of in accordance(\ with this permiton:
li Date of Disposition `1-'I*lt Place of Disposition Fsvrr� Cr-WC04�-
` (address)
WVI
0 (section) (lot number) (grave number)
0it4 .,,
Z Name of Sexton or Person in Char a of Premises ili(f .c1M -"�
(please print)
Signature (14Title Cie?. Tb1L
(over)
DOH-1555(02/2004)