Williams, Kenneth Rolland r
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kenneth Rolland Williams Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/16/2023 91 Years War or Dates 1951-1955
Place of Death Hospital,Institution or
WCity,Town or Village South Glens Falls Village Street Address 45 Saratoga Avenue,South Glens Falls Village,New York 12803
0 Manner of Death ❑X Natural Cause Accident ❑Homicide Suicide Undetermined ri Pending
LU
Circumstances Investigation
W Medical Certifier Name Title
0 Thomas Coppens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Village Of South Glens Falls District Number Register Number
City,Town or Village 4524 22
L Burial Date Cemetery,Crematory or Facility Name
12/21/2023 Pine View Cemetery
Entombment Address
Cremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
O
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/18/2023 Registrar of Vital Statistics Samantha Berg g ctronicail:y Signer!)
(signature)
District Number 4524 Place Village Of South Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition ),,D, DI, a `? Place of Disposition • \Cur C
(address)
liu G i cc -
N (sectio -- --1 (lot number) (grave number)
CC / 1 JJ
SName of Sexton or Person in Charge of Premises
Z (please print)
W Signature �A Title ` j`. Q' fl
DOH-1555(07/18)p 1 of 2
11 7 k 4
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#
WILLIAMS
(1,..i
� Lot No. 7
Address 45 Saratoga Ave. So. Glens Falls, N.Y. 12803 Section No. E
Owner Kenneth & Ernestine Williams Plot Mohican
Date 4/25/89
Approx. 100 Superficial ft. @
Location Bounded on North by Vacant, South by Scallero, East by Gratton & Measeck,
West by Vacant.
Corner Posts
Remarks
Deed No. (and changes) 2205
Payment Record pai r3 in Pull 4/25/R9
Record of Interments
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Form No. 01
WILLIAMS
NAME Kenneth R. Williams Age: 91
Lot Owner: Kenneth & Ernestine Williams
Lot# Mohican 7E Grave# 1
Case: Concrete
Died: 1 2 . 1 6.2 3 Interred:1 2.21 .a2
Funeral Home: Kilmer FH
Cemetery: Pine View