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Matraw, Kenneth W
.___ _ e 1 7 69 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kenneth W Matraw Male Date of Death Age If Veteran of U.S.Armed Forces, 12/03/2020 56 Years War or Dates l— Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc Ill p Manner of Death © Natural Cause ❑Accident 1=I Homicide El Suicide El Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title O Carrie Miron PA Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 101 Burial Date Cemetery,Crematory or Facility Name 12/05/2020 Pineview Crematory ElEntombment Address ]Cremation Queensbury Town,New York ElDonation Z Removal Date Place Removed and/or and/or Held H Hold Address N 0 d Date Point of V) ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address Q W CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/04/2020 Registrar of Vital Statistics Aimee Mahoney(Electronically Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- � / Z Date of Disposition �,w ,Qp�jj Place of Disposition 'ji v e Lie'es-3t.r, -n4-to W 2 (address) ILI NCr (section) (lot number) (grave number) 0 Name of Sexton or Person in Ch rge of Premis � yi/�7f °�[' cJF. � Z (please print) W Signature y�f ,: Title C'7r 1 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) ' 1. 4.2 q i. Receipt Human remains ofr' delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#