McMahon, Kenneth NEW YORK STATE DEPARTMENT OF HEALTH t 3 !,.3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kenneth Bryant McMahon Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 17, 2012 68 War or Dates
H Place of Death Hospital, Institution or
W
City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death 0 Natural Cause Ell Accident 0 Homicide 0 Suicide 0Undetermined ri Pending
Circumstances Investigation
11.1 Medical Certifier Name Title
Ci Marvin Davidowitz, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Numbe 0 i Regi r 1mber
City, Town or Village
❑Burial Date Cemetery or Crematory
July 18, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
and/or Address
E_ Hold Pine View Crematorium
CO Date Point of
ti_ Ell Transportation Shipment
0. by Common Destination
CI Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
C:.
Ill
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued -7) / i//2 Registrar of Vital Statistics GIAio-t4 k_A}
(signature)
District Number 5 60 1 Place 6 reA t. tS t\J Le)
t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 1-1,0-H2 Place of Disposition .2,.i,V& eft r 1,,,`
W (address)
CO
it (section) (lot number) S (grave number)
p Name of Sexton or Person in Charg of Premises ilydit tha{'
�. ( lease print)
ni SignaturearI — Title CA6.911-174/
(over)
DOH-1555 (02/2004)