McKinney, Glenn NEW YORK STATE DEPARTMENT OF HEALTH` " 3
Vital Records Section : �* Burial - Transit Permit
Name First Middle Last Sex
Glenn Thomas Mc Kinney Male
Date of Death Age If Veteran of U.S. Armed Forces,
iM 01/16/2013 48 years War or Dates No
f Place of Death Hospital, Institution or
.141 City, Tom Schenectady Street Address Ellis
Manner of Death atural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
lea Circumstances Investigation
iii Medical Certifier Name Title
L Miroslav Vytrisal M D
Address
1101 Nott St, Schenectady, N Y 12308
Death Certificate Filed District Number Register Number
City, To v xVj IX Schenectady 4601 53
❑Burial Date Cemetery or Crematory:iii
❑ ntombment 01/17/2013 Pine View Crematorium
iiiiiAddress
:remation Quaker Rd, Queensbury, N Y '
Date Place Removed
Z Removal and/or Held
0 ❑and/or
i Address
Hold
til
Date Point of
to Li Transportation Shipment
G by Common Destination
Mi Carrier
❑Disinterment Date Cemetery Address '
Iiii ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address _
in 68 Main St, Box 67, Hudson Falls, N Y 12839
Rilii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above ,
Address
IX
111
IL
Permission is hereby granted to dispose of the human rernai s. escr ed a ve at i - ated.
Date Issued 01/16/2013 Registrar of Vital Statistics0 ? 1� ,c
ij
(signature)
District Number 4601 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I ' f !_
L Date of Disposition 1.-Ig~i? Place of Disposition giUh,J C.lY/In:40
2 (address) l`
tO
I (section) �� (lot number)c (grave number)
CI Name of Sexton or Person in Charge of Premises f he) • Evoilr
2r /�/ (please print)
41, Signature l 6 �t,S" Title Ci eolitk 00
(over)
DOH-1555 (02/2004)