Bamberger, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH 41 113
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Kenneth Edward Bamberger I Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/18/2012 65 War or Dates Vietnam
Place of Death Hospital, institution or
City,Town or Village Brant Lake Street Address Deceased's Residence
Manner of Death Natural Cause Q Accident D Homicide Q Suicide El Undetermined 0 Pending
Circumstances Investigation
Ili Medical Certifier Name /� Title
Ct WILLIAM C. ORLUK, ✓1 -
Address
6223 State Rte 9 Chestertown, NY 12817
Deal ificate Filed // District Number Register Number
Cit�or Village / /7 by.) . -
U67
El Burial �j / or Creme-on}
Entombment Dad-e 4 `�'o` Gee m713 2 Ge t�jte•latl l/v v-+-7
LCremation Address C?(/aA &)(/-‘e-W-C-'17 Zi/X /WO�
Date Place Removed
Z El Removal
and/or Held
0 Hold Address
f-
Date Point of
flTransportation Shipment
4 by Common Destination
0 Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
L Remains are Shipped, If Other than Above
2 Address
w
Permission is he by gr ted to dispose of the human rem` s described above T
Date Issued � Registrar of s Ind' ated.
_ . Vital Statistics
-A' ,) Gr
�� (signature)District Number 5-.Z7 Plac_. w-4-7 0 G,%/rG;-)7 1(f11/i'<u-/ - -.7 .71
Z2.1--,cr-
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui
ui Date of Disposition 1-Z I-IL Place of Disposition 'Cia kit,v Cr e4Ocw—
g (address)
W
le (section) (lot number) (grave-number)
0 A,)-kcil,r- L)e.,4If
Name of Sexton or Person in Charge o remises
(please print)
W Signature 7//( e Title G/W-241 KUL
(over)
DOH-1555(02/2004)