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Ketchum, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH ' i+ ft 3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Ate; Lawrence Edward Ketchum Male _' Date of Death Age If Veteran of U.S. Armed Forces, -_ April 3, 2014 54 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending Circumstances Investigation ' ', Medical Certifier Name Title Paul F. Bachman, Address ti , 3767 Main Street Warrensburg, NY 12885 Death Certificate Filed District Number �� Register,Nu i � City, Town or Village Glens Falls ll 11 ❑Burial Date Cemetery or Crematory April 8, 2014 Pine View Crematory ❑EntombmentIlk Address ®Cremation Quaker Road Queensbury,NY 12804 :Tip Date Place Removed ❑ Removal and/or Held -z i and/or Address Hold Date Point of ❑Transportation Shipment xa:' by Common Destination Carrier ❑ Disinterment Date Cemetery Address 4 ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home 01078 } Address F -' 136 Main Street, South Glens Falls NY 12803 RI: 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 remains described above as indicated. Date Issued N )g /I 9 Registrar of Vital Statistics t.j)CA._&1yr2, UU.J~� tG(signa re) : District Number 5 l,© / Place 6 cs2„,.._S c-QA k\c ) lv u x= I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i Date of Disposition 04/08/2014 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) A (lot number (grave number) Name of Sexton or Person in harge of Pre ises ti4iNiollow ',er"' ' (please print) ,,,„, Signature Title CgrortlY (over) DOH-1555 (02/2004)