Kelsey, Charles Richard NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charles Richard Kelsey Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/20/2020 81 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
W Manner of Death g
Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 50
Burial Date Cemetery,Crematory or Facility Name
03/24/2020 Pine View Crematory
Entombment Address
1 Cremation Queensbury Town,New York
Donation
OZ Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
Date Point of
8 Transportation Shipment
a
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
JE]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
E- Remains are Shipped,If Other than Above
2 Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/24/2020 Registrar of Vital Statistics Carnlrnexl�legarde Badder(--lectronwa-5SOne4
(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:
W Date of Disposition 3—,y,S=Zazp Place of Disposition �,�e t,�
C
Uj (addr s
W
(section) (lot number)
)j (gra ve number)
Name of Sexton or Person in C arge of Pr ses Ft �. OvC'
/please print)
W Signature S Title
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013460
Receipt
Human remains of R `+` delivered on , 20
ram-
Pine View Cemetery Re ti g the funeral home named on burial permit
Official Funeral Dir tors Reg.or License#