Hammer, Kenneth it it
NEW YORK STATE DEPARTMENT OF HEALTH ` to
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kenneth O. Hammer Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 2,2013 65 War or Dates Vietnapm
. Place of Death Hospital, Institution or
Z City, Town or Village Bolton Street Address 126 Retreat Rd. Diamond Point
• Manner of Death I XI Natural Cause Accident Homicide Suicide I I Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Gary Scidmore Coroner
Address
6930 State Rt.8,Brant Lake,NY 12815
Death Certificate Filed District Number Register Number
City, Town or Village T/O Bolton 5650 9
❑Burial Date Cemetery or Crematory
❑Entombment August 5,2013 Pine View Crematory
Address
EJ Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
O Date Point of
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
i— Remains are Shipped, If Other than Above
2 Address
0-
Permission is hereby granted to dispose of the human remains descrbed ove as indicated.
Date Issued 8-5-13 Registrar of Vital Statistics /"
(signature) 66
District Number 5650 Place T/O Bolton,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /tof i3 Place of Disposition 'r((��nr.. C ,Sto(Vr
(address)
W
CO
(section) (lot nu ber) (grave number)
QName of Sexton or Person Charge of remises rtifi ✓ Sevrlt
Z (please pint)
W Signature Title Cli iifl�e
(over)
DOH-1555(02/2004)