Kelly, Charles b
NEW YORK STATE DEPARTMENT OF HEALTH s
Vital Records Section Burial - Transit Permit
Name First Middle Last . Sex
CHARLES E. KELLY MALE
Date of Death Age If Veteran of U.S. Armed Forces,
12/16/06 _ 81 War or Dates WW 2
.. Place of Death Hospital, Institution or
City, Town or Village Lake Placid Street Address Adrk Medical Center
Manner of Death x❑Natural Cause ❑Accident ❑Homicide ❑Suicide 1-1 Undetermined ❑Pending
Circumstances Investigation
la Medical Certifier11 Name Title -
AO H V W Bergamini , MD
Address
Swiss Road., Lake Placid, NY
Death Certificate Filed District Number Register Number
iiiiiii`> City, Town or Village Lake Placid 1560
Date Cemetery or Crematory
LIBuriai 12/19/06 Pine View Crematnry
Address
: UCremation Glens Falls, NY
Date Place Removed
Z❑Removal and/or Held
rz and/or Address
Hold
Date Point of
N Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address •
Reinterment Date Cemetery Address
*<> Permit Issued to Registration Number
<= Name of Funeral Home M B Clark, inc. 01146
;: Address
2310 Saranac Ave. , Lake Placid,1 NY
<<.::: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
ffl Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/18/06 Registrar of Vital Statigtics' 1 C S 3_ �` L'
g� �4 a V"� �,i � . �.l _ V�.��i a �`
(signature) - V
il District Number 1560 Place Lake Placid (North Elba ) , NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
WDate of Disposition (a/1 c w(o Place of Disposition ?ins-v 4 -' (rMr"f c.r t Id A
2 (address)
LU
Cl) .
C (section) lot number) (grave number)
0 Name of Sexton or Person in arge of.Premises ( 1-0S n nii �. .1
C3 // (please print) .,
Signature L Title C r Qrn n �`
DOH-1555 (10/89) p. 1 of 2 VS 61