Kelly, Elizabeth i.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
-r Name First Middle Last Sex
Elizabeth Jean Kelly Female
viz Date of Death Age If Veteran of U.S. Armed Forces,
`< December 1,2016 90 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death
Medicl Cer
X Natural Cause Accident Homicide n Suicide Undetermined n Pending
Circumstances Investigation
v . <--- Ida ' Cbtiti
a Name Title
: & \..e.cs -4:Lir i..).1
:r
Death Certificate Filed / District Number Register Number
%3 City, Town or Village Fort Edward,NY 5755
®Burial Date Cemetery or Crematory
December 5, 2016 Pine View Cemetery
❑Entombment Address
❑Cremation - Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N ❑Transportation Shipment
'p by Common Destination
Carrier
pi Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
I Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
. Address
'' 407 Bay Road, Queensbury, NY 12804
>: Name of Funeral Firm Making Disposition or to Whom
�,�
r<
Remains are Shipped, If Other than Above
,may Address
V Permission is hereby granted to dispose of the hum ' s describ d aaIove as dicated.
-sa
� Oplq) Y��;� Date Issued � Registrar of Vital Statistic
(signature)
;,A .------- eds-oevt_d_
District Number sq65 Place I b--10-)k 0'6
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1 2/5/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
N Seneca 13C 2
♦Y (section) (lot number) (grave number)
O Name of Sex or Person in Charge of Premis Connie T•_ GO iprt
G Z (please print)
Ill Signature Title Cemetery Superintendent
(over)
DOH-1555(02/2004)