Kennedy, Michael NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit� �rmit
Name First Middle Last Sex
Michael W Kennedy Male
Date of Death Age If Veteran of U.S.Armed Forces,
June 8, 2013 Sb War or Dates
2 Place of Death Hospital, Institution or
W City,Town, or Village North Granville Street Address Residence
Manner of Death Natural Cause El Accident Ei Homicide 0Suicide El Undetermined Pending
Circumstances Investigation
(,J Medical Certifier Name Title
Dr. Carl Beckler, M.D. Dr.
Address
278 Vt. Route 149, West Pawlet, VT 05775
Death ificate Filed District er Register Number
City, ow or Village -N h--ertGranville (30
❑Burin Date Cemetery or Crematory
June 11, 2013 Pineview Crematorium
❑Entombment Address
0 Cremation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued to l O 'ej('S Registrar of Vital Statistics T-4
nature)
District Number ,`j rJ La Place Mg= Granville, w York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
w Date of Disposition 06/11/2013 Place of Disposition Pineview Crematorium
2 (address)
(section) of nu ber) (grave number)
CI Name of Sexton or Person in Charge of Premises ��1 .4 r �1
(pleae print)
Signature / e✓ ' "*J- Title C-Jr'7 Y(
(over)
DOH-1555 (02/2004)