Cannan, Kenneth S. 4q01
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kenneth S.Cannan Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/11/2022 54 Years War or Dates
Place of Death Hospital,Institution or
Z City,Tpwn or Village Indian Lake Town Street Address 5939 State Route 30, Indian Lake Town, New York 12842
Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
CI Matthew Miller Coroner
Address
P.O.Box 250, Indian Lake,New York 12842
Death Certificate Filed Town Of Indian Lake District Number Register Number
City,Town or Village 2053 4
Burial Date Cemjetery,Crematory or Facility Name
05/18/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Townlew York
Donation
Q❑Removal Date Place Removed
and/or and/or Held
- Hold Address
O
CL Date Point of
N❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
Q
LL!
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/16/2022 Registrar of Vital Statistics Julie A Clawson(Electronically Signed)
(signature)
District Number 2053 Place Town Of Indian Lake
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /y,
Z Date of Disposition 6-1 lq lu Place of Disposition s�� Lt�
W (address)
Et W �}
N (section) (lot number/�^ 1 J (grave number)
GName of Sexton or Person in Charge of Premisesipt
Z (p/ se print)
W •Signature Title iK
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
1 Receipt
1 Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#