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Steele, Kenneth Brian (ID it ti,i NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kenneth Brian Steele Male Date of Death Age If Veteran of U.S.Armed Forces, 06/11/2023 72 Years War or Dates H Place of Death Hospital,Institution or W City,Town or Village Fort Ann Town Street Address 5232 Pillar Way,Fort Ann Town,New York 12827 p Manner of Death ❑X Natural Cause IllAccident El Homicide Duicide ElUndetermined El Pending W Circumstances Investigation W Medical Certifier Name Title O Joseph Mihindukulasuriya MD Address 20 Murray Street,Glens Falls,New York 12801 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 10 Burial Date Cemetery,Crematory or Facility Name 06/16/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address W 0 Date Point of Cl) Transportation Shipment p by Common Carrier Destination ElDisinterment Date Cemetery Address Date Cemetery Address ElReinterment 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 1— Remains are Shipped,If Other than Above 5 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/14/2023 Registrar of Vital Statistics Miranda 7ferringshaw(ECectronicaCCy Signed) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ �` 4, — W Date of Disposition (p I iZ 1 Z3 Place of Disposition (address W WCC (section) (lot num (grave number) ft a Name of Sexton or Person in Charge of Pr s / 11. Z (please print rffrPA7g7 W Signature Title DOH-1555(07/18)p 1 of 2 1! 7 0LI8 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 -. Pine View Cemetery Representing the funeral home named ou ptuial permit Official Funeral Directors Reg.or License#