Gunn, Kenneth A 9/ot-
NEW YORK STATE DEPARTMENT OF HEALTH ''‘ f Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kenneth A Gunn Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/24/2023 61 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Moriah Town Street Address 2779 Center Road,Moriah Town, New York 12960
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I Manner of Death I Natural Cause Accident I I Homicide Suicide Undetermined Pending
C.) I Circumstances Investigation
W Medical Certifier Name Title
G Melanie Duerr NP
Address
47 Tom Phelps Lane,Mineville Hamlet,New York 12996
Death Certificate Filed Town Of Moriah District Number Register Number
City,Town or Village 1558 30
idBurial Date Cemetery,Crematory or Facility Name
11/29/2023 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
Donation
O[ ]Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a Date Point of
Cl)IIITransportation
p by Common Shipment
Carrier Destination
[]Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
N Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/28/2023 Registrar of Vital Statistics &se 1 French(E/ctronicaf Signed)
(signature)
District Number 1558 Place Town Of Moriah
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II-- /
Z Date of Disposition /`2 9 zo%j Place of Disposition e r.) Q Vet CI`lipie,-Fp j--
W
2 (address)
iii
N
CC (section) (number) (grave number)
0 '
Name of Sexton or Person in Charge of Premise ��Albf�� j
W /, (please print/
Signature s✓' / Title 0093 401-
G
DOH-1555(07j18)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#