Waite, Kenneth Charles Jr. NEW YORKSTATE DEPARTMENT OF HEALTH LF
It SiloBureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Kenneth Charles Waite Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/27/2022 91 Years War or Dates
}... Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Ili
p Manner of Death El Natural Cause []Accident []Homicide Suicide []Undetermined Pending
0 I (Circumstances Investigation
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0 Medical Certifier Name Title
Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 335
Burial Date Cemetery,Crematory or Facility Name
06/29/2022 Pine View Crematory
[]Entombment Address
Cremation Queensbury Town,New York
Donation
0 Rem L_Joval Date Place Removed
H and/or and/or Held
Hold Address
0
d Date Point of
U)❑Transportation
El" Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
"" Address
CC
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a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/28/2022 Registrar of Vital Statistics gOegan Wolin('E1ectronica1TySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition /�`11 Place of Disposition
474. ��6 "
2 (address)
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CC (section) x (lot number) Swoi (grave number)
gName of Sexton or Person in urge of Premises rt
( ase print)IIIJ `
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Signature Title 0?/ Vl1'11 Aft,
DOH-1555(07/18)p 1 of 2
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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 Funer, License#