Willett, Kelly Jean 'f (�L
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kelly Jean Willett Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/26/2020 51 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 35 Briwood Circle,Queensbury Town, New York 12804
WW Manner of Death Undetermined Pending
1^1Natural Cause Accident Homicide Suicide
� Circumstances Investigation
W Medical Certifier Name Title
C John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Villa a Queensbury 5657 31
Burial Date Cemetery,Crematory or Facility Name
02/27/2020 Pine View Crematory
Entombment Address
ZCremation Queensbury Town,New York
Donation� ❑Removal Date Place Removed
and/or and/or Held
H N Hold Address
O
LL Date Point of
V) Transportation
a by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
}.. Remains are Shipped,If Other than Above
Address
W
111' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/27/2020 Registrar of Vital Statistics CaroA--- frla<garde oar,er(Ekctrunwa/tySrgneq)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
Z Date of Disposition 2 j 1'I 7o Place of Disposition ti„' 40.(wry..
g (address)
W
N (section) (lot number) ( (grave number)
41
S Name of Sexton or Person in Charge of Premises f
(plea print/
Z
W Signature (/' Title
DOH-1555(07/18)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#