Torrance, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH l `"y
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
KENNFTH R. TORRA\CF. MALE
Date of Death Age If Veteran of U.S. Armed Forces,
03/20/12 96 War or Dates U S AIR FORCE
Place of Death Hospital, Institution or
ithiCity, Town or Village HARRIETSTOWN Street Address ADRK MEDICAL CENTER
0 Manner of Death a Natural Cause Ei Accident rj Homicide L3 Suicide El Undetermined 0 Pending
tli
0 Circumstances Investigation
l<tj Medical Certifier Name Title
DAVID A. JOHNSON, MD
Address
ADRK MEDICAL CENTER SARANAC LAKE, NY
I' Death Certificate Filed District Number Register Number
> City, Town or Village HARRIETSTOWN 1663
' a❑Burial Date Cemetery or Crematory
03/20/12 PINE VIEW CREMATORY
❑Entombment Address
` ®Cremation GLENS FALLS, NY
Date Place Removed
❑Removal and/or Held
and/or Address
'. Hold
Vf
0 Date Point of
fti El Transportation Shipment
el by Common Destination
Carrier
``: Disinterment
Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. CLARK, INC. 01075
Address
2310 SARANAC AVE. , LAKE PLACID, NY V. -ciL{to
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LEI
Permission is hereby granted to dispose of the human remains described above as 'ndicated.
Date Issued 0 3/21/12 Registrar of Vital Statistics
(signature
District Number 1663 Place Villag of Saranac Lake
: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
tW Date of Disposition3',2�p/2 Place of Disposition re tit e ./ CUt'yiar(c�f tt)WI
(address)
Ili
CA
CC (secti (I t number) (grave number)
i Name of Sexton or Person in Charg of Premises (t ii O�by cm e//C
z (please riot)
Signature s Title C rem 4'fore ;liti
.s
(over)
DOH-1555 (02/2004)