Loading...
Keene, Jr. Burt 1.4 #7g Z r NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit L1 Name First Middle Last Sex Burt Moran Keene,Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, 9/24/2018 69 War or Dates NA A Place of Death Hospital, Institution or City, Town or Village Town Of Granville Street Address 271 Route 22A Manner of Death ❑X Natural Cause ❑Accident ❑Homicide n Suicide n Undetermined n Pending `I Circumstances Investigation 1r= Medical Certifier Name Title ' George Knapp DO Address 520 Maple Ave.,Saratoga Springs,NY 12866 Death Certificate Filed District Number Register Number VW City, Town or Village Town of Granville,NY E 73 6 yr] ❑Burial Date Cemetery or Crematory September 27,2018 Pine View Crematorium ❑Entombment Address J Cremation 51 Quaker Road,Queensbury,NY 12804 Date Place Removed ZZ Removal and/or Held and/or Address H Hold N O Date Point of Q. ❑Transportation Shipment p by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Oi Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 14 Address Sql 407 Bay Road,Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above a�sindicated. *� Date Issued Dq f a 7 IaD ls' Registrar of Vital Statistics rjsignn �� nature) District Number Place ')"purl) ©F i2 Mvit,t,6 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition ili RA,.4IS Place of Disposition RA,. W (address) CO re (section) (tot number) (grave number) QName of Sexton or Person in Charge of Premises Il t.,t i-V S `Z (pt ase print) 11 Signature a j Title ( /Vat (over) DOH-1555(02/2004)