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Weller, KellyNEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Name First Kelly Dean Weller Date of Death 10/20/2019 ��Ag Years Place of Death City Town V'll If Veteran of U.S. Armed Forces, ,or Dates Ju I or i age Northumberland Town Manner of Death ©Natural Cause Accident Medical Certifier Name Eugene Ladue Address 31 Woodlawn Ave., Saratoga Springs, New York 12866 Death Certificate Filed Last $ bqg Burial - Transit Parm;+ Sex Male . .62216 Hospital, Institution or Street Address 1816 N 32 Route, Northumberland Town, New York 12831 Homicide 11Suicide Undetermined ElPending Title Circumstances Investigation Coroner City, Town or Village Northumberland Town District Number 11 4563 Burial Date Cemetery, Crematory or Facility Name Entombment 10/24/2019 Pine View Crematorium My Address Cremation Queensbury Town, New York Donation Removal Date Place Removed and/or and/or Held Hold Address Transportation Date Point of by Common Shipmei Carrier Destination Disinterment I Date Cemetery Address Reinterment L Date Cemetery Address Permit Issued to Name of Funeral Home Carleton Funeral Home Inc Address 68 Main Stpo Box 67, Hudson Falls, New York 12839 Name of Funeral Firm Making Disposition orto Whom Remains are Shipped, If Other than Above Address Register Number 4563 Registration Number 00281 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/2412019 Registrar of Vital Statistics 'Denise gDWurphy (ElectronicallySigned) District Number 4563 Place Northumberland Town, New York ) certify U the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition (pl Ig (15- Place of Disposition NatnE Sexton or Person in Charge at Premises Signature Title DOH -tom 5551o7n8) P 1 of 2 Public Health Law Sec. 4145(2b) 013023 Receipt Human remains of 1 ` k ', .' ' ' FT delivered on , 20 ; r ���4 � � , Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License #