Popeck, Kenneth Andrew 1i)
NEW YORK STATE DEPARTMENT OF HEALTH * ' Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kenneth Andrew Popeck Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/09/2020 63 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Hudson Falls Village Street Address 103 John Street, Hudson Falls Village,New York 12839
p Manner of Death ❑X Natural Cause I=1 Accident Ei Homicide 1=1 Suicide Undetermined El Pending
W C.) Circumstances Investigation
UJ Medical Certifier Name Title
Umbreen Rozell MD
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Hudson Falls Village 5726 39
Burial Date Cemetery,Crematory or Facility Name
12/11/2020 Pine View Crematory
Entombment Address
EjCremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
- Hold Address
N
0
a Date Point of
NLj Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
lr Remains are Shipped,If Other than Above
a Address
ii
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/11/2020 Registrar of Vital Statistics Cynthia.?Bardin(Electronica45'Sgned)
(signature)
District Number 5726 Place Hudson Falls Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 1Z�1/ho Place of Disposition
(address)
mod"
Ui
Et
N (section) ( (lot number) (grave number)
GName of Sexton or Person in Charge o P emises /�r."0 �o"l't�ft
Z /p! seSe print/
Ui Signature Title
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) -� 1 4 P r)7
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#