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Mallory, Kenny Wayne Rogers # 171 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kenny Wayne Rogers Mallory Male Date of Death Age If Veteran of U.S. , 02/14/2022 37 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 0 Manner of Death ©Natural Cause ❑Accident 0 Homicide Ei Suicide 0 Undetermined El Pending 111 0 Circumstances Investigation Medical Certifier Name Title G Jeremy Di Bari MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 111 ElBurial Date Cemetery,Crematory or Facility Name 02/24/2022 Pine View Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Removal Date Place Removed is 0and/or and/or Held ~ Hold Address N 0 taf) ❑Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/16/2022 Registrar of Vital Statistics Megan Nolin(E1 ctronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 2 114 in Place of Disposition c17,4(,L 61 a (address) W 2 (section) 1 (tot number) (grave number) SName of Sexton or Person in Charg of Premises ii,,,„- L- J(t Z (p4se print) W Signature Title �? * �rt DOH-1555(o7/18)p 1 of 2 115C27 1 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#