Kane Jr, John NEW YORK STATE DEPARTMENT OF HEALTH f i ,A $ II(
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
h i1) NEAi/VI /<AW E , "4_ /14/0
Date of Death Age If Veteran of U.S. Armed Forces,
A'lAA- '- 19 0 War or Dates /1;2-k--ty rUi1//.ivot,J.v,
i- Place of Death Hospital, Institution or
6i#p, or-�.iuoge///0/2/2d -trOtAi i Street Address A ,h/c._ it--/e.%t( (, Cei-t,j 2&_
0 Manner of Death Natural Cause Accident 0 Homicide Suicide Undetermined �Pending
tJ1 Circumstances Investigation
w Medical Certifier Name Titl
A�7NUNf F". Le)iti6 it..)/ /fib
Address
z -3 3 g Jo ---' 4f , 54/14404 t, Like„,ke„, N t/ l(Zc c 3
Death C rtificate Filed District Number Ai.(5 Register Number
city, ow9�brb4Nage�i�AQ1L/Ir'S"x"Ja
[]Burial Date
,�j Cemetery,/� or Crematory
❑Entombment , `A2 `� /�//Ve Oei-i ejZG/t-bo v
Address /
Cremation J 3!J/4 Ica-A-- , ( �i'eaka A./.1 ivy 1716 /
Date Place Removed
z, Q Removal and/or Held
and/or Address
: Hold
10
0 Date Point of
!L riTransportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to A Registration Number
Name of Funeral Home/f, R. CL/IL/L )L IA . alb?S�
Address
310 SA 2,A,JAL Are, , Ly4x A.Aoo, �u Iz.3V
Name of Funeral Firm Making Disposition or to Whom /
}_: Remains are Shipped, If Other than Above
2 Address
is
w
3• Permission is hereby granted to dispose of the human remains described abo as indic ed.
Date Issued 3 — ' e2O" / Registrar of Vital Statistics
(signature)
District Number/ d3 Place Village of Saranac Lake
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
tti Date of Disposition 3/4111 Place of Disposition wtf'..„ Cam-. arc-`
(address)
La
VI
CC (section) . (lot number) (grave number)
D Name of Sexton or Person in Charge of Premises P°' 'L 9`..
ait y A (please print)
SignatureW. Title
(over)
DOH-1555 (02/2004)