Killeen, Jeffrey M . Li— \ 993
NEW YORK STATE DEPARTMENT OF HEALTH a\- �
. ' Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeffrey M.Killeen Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/14/2022 69 Years War or Dates
Place of Death
F— Hospital,Institution or
WCity,Town or Village Lake George Town Street Address 3644 Lake Shore Drive,Lake George Town,New York 12824
p Manner of Death El Natural Cause ❑Accident Homicide ESuicide E=IU Pending
W U Circumstances Investigation
UJ Medical Certifier Name Title
Tanya Finch NP
Address
9 Carey Road,Queensbury Town, New York 12804
Death Certificate Filed Town Of Lake George District Number Register Number
City,Town or Village 5651 23
Burial Date Cemetery,Crematory or Facility Name
12/16/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
0. Date Point of
Cl)El Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg, New York 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
Ir
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/15/2022 Registrar of Vital Statistics Patricia RMcKinney-Schuster(ECectronicalrySigned)
(signature)
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
W Date of Disposition /2/7 7eZZ Place of Disposition e ,e �:e j Cr,,14, r
2 (address)
W
U)
Q (section) (lot number) (grave number)
8 Name of Sexton or Person in Ch e of Pre ises '�i3i1/'5 I J
Z I (please print)
MISignature 4 Title (?e'PS'4.'li"-c"
DOH-1555(o7/18)p 1 of 2
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#