Skellie, WilliamNEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records
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Burial - Transit Perr it
Name First Middle Last
Sex
William John Skellie Jr.
Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
09/16/2019
86 Years
War or Dates 1953-1955
F
Place of Death
Hospital, Institution or
Z
City, Town or Village Queensbury Town
Street Address 15 Seward Street, Queensbury Town, New York 12804
W
0
Manner of Death Undetermined Pending
Natural Cause Accident ❑ Homicide Suicide g
W
Circumstances Investigation
U
W
Medical Certifier Name Title
93
Mark Quaresima MD
Address
9 Carey Road, Queensbury Town, New York 12804
Death Certificate Filed
District Number
Register Number
City, Town or Village Queensbury
5657
138
❑ Burial
Date
Cemetery, Crematory or Facility Name
09/17/2019
Pine View Crematory
Entombment
Address
17 Cremation
Queensbury Town, New York
Donation
Z
Removal
Date
Place Removed
and/or Held
U-
and/or
Hold
Address
N
O
a
Date
Point of
to
Q
Transportation
Shipment
by Common
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
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/17/2019 Registrar of Vital Statistics CaroCrneJ91,0--yarde BarAer(ElectronicaiiySigned)
(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:
I—
`/
v
Z
1/� --
Date of Disposition �IS�IS Place of Disposition , G.,
LU
2
(address)
W
N
(section) / (!ot number/ (grave number)
a
0
Name of Sexton or Person in Charge of Premises r�fr
lease print/
� 6wifIV. i
W
Signature Title
o
DOH-1555 (07/18) p t of 2
Public Health Law Sec. 4145(2b)
012541
Receipt
Human remains of L delivered on
Pine View Cemetery
Official
'7' 20'
REpresenting the funeral home named on burial permit
Funeral Directors Reg. or License #