deBeaumont, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH f __ ' Burial - Transit Kermit
Vital Records Section
Name First Middle Last Sex
Kenneth C. deBeaumont Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 23, 2013 70 War or Dates
1,,.. Place of Death Hospital, Institution or
Z City, Town or Village Gansevoort Street Address 9 San Luis Rd
pManner of Death n Natural Cause Accident Homicide n Suicide l i Undetermined n Pending
11.1
Circumstances Investigation
uj Medical Certifier Name Title
G Edward Liebers MD
Address
3 Care Lane Suite 3000, Saratoga Springs,NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Northumberland 1.-j 51.0 3 1 9---
0 Burial Date Cemetery or Crematory
❑Entombment November 25, 2013 Pine View Crematorium
Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ]Removal and/or Held
and/or Address
H Hold
N
d Date Point of
es Ti Transportation Shipment
p by Common Destination
Carrier
Ti Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
it
W
a
Permission is hereby granted to dispose of the human
remains described above as indicated.
Date Issued IN\°as1 ap 13 Registrar of Vital Statistics 1.1�n
.,93-\y_A
(signal re)
District Number (--\563 Place North Umberland u
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lu
v �,
Date of Disposition If-l(0'13 Place of Disposition k -ellatius—
Ill (address)
N
0 (section) (lotnu ber) (grave number)
Z Name of Sexton or Person in Ch rge of Premi es G ^oh ..c 4df'
Ill
e print)
Signature !L— Title GRrr�A
(over)
DOH-1555(02/2004)