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Kennison, John NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex John H. Kennison _ Male .- ..... ... ...... .......... ............. ........ _-. ....... ... Date of Death Age If Veteran of U.S.Armed Forces, Jul 20 1992 67 War or Dates III y . ...::::::.:: _. Z Place of Death Hospital, Institution or W City,Town or Village City of Glens Falls Street Address Glens Falls Hospital. WManner of Death © Natural Cause Accident Homicide Suicide Undetermined ❑ Pending Circumstances Investigation ;W, Medical Certifier Name Title ...... .... James..Xouanof ..:.: : ::.._- MD ___ _ Address S2,.Park..Street.,...Glens..Falls,..1 Y-12.801 ... . Death Certificate Filed District Number RegisteOur�ber City,Town or Village /off J Date Cemetery or Crematory El Burial Ju1y..22I 1992 Pine View:Crematoxy.:,. ........... .. .:..:.....::::: ®Cremation Address .. Queensbury,. NY Z Date Place Removed O ❑ Removal and/or Held F- and/or Hold Address to O.. ......... _. a Date Point of _ .... cn Transportation by Shipment p Common Carrier ......: Destination ...... _ Disinterment Date Cemetery Address _ __.._.._ ...:..... . :..... Reinterment Date _ _ Cemetery Address Permit Issued to Registration Number Name of Funeral Firm d L.... e y.Fu ;Ed,Hcme - 01073 Address Main Street Lake, NY Sc 12870 ._t . H: Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above .. ....... . :. ::W Address n> Permission is hereby granted to dispose of the h an rr in cribed above as indicated. Date Issued 7/22/92 Registrar of Vital Statistics (signature) District Number 5601 Place City of Glens Falls 1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Z . ace of Disposition �/� O� ��'',cc�l,rg To/f i"" j w g (address) W (section``) (lot number) (grave number) pName of Sexton o Person in arge of Premises Z (please print) T w Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61