Ackley, KIenneth / `N # 3 ZO
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
,` Name First Middle Last Sex
Kenneth E. Ackley Male
' Date of Death Age If Veteran of U.S. Armed Forces,
May 16,2014 73 War or Dates Vietnam
.' Place of Death Hospital, Institution or
City, Town or Village T/O Thurman Street Address 9 Bowen Hill Rd.
'' Manner of Death g Natural Cause 'Accident Homicide Suicide lUndetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
3: Paul Bachman MD
Address
HHFIN,Warrensburg,NY 12885
=ha Death Certificate Filed District Number Regist r umber
City, Town or Village T/O Thurman 5659
❑Burial Date Cemetery or Crematory
May 19,2014 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N n Transportation Shipment
p 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
ikRi Remains are Shipped, If Other than Above
Address
I
Permission is hereby granted to dispose of the human r ins described a v i di ted.
Date Issued 5-19-14 Registrar of Vital Statistics ,
(signatur
-; District Number 5659 Place T/O Thurman,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 5/701 IW Place of Disposition Zi01,,,, C4 .tcf
2 (address)
W
U)
CL (section) d•,1„,././...^
(lot number) (grave number)
pName of Sexton or Pers in Charge of Premises ++Z ease print)
W Signature /IL / .... Title atiCA �1TZei
(over)
0OH-1555 (02/2004)