Tonner, Niles sKn
NEW YORK STATE DEPARTMENT OF HEALTH • - Burial - Transit Pern�ii
Vital Records Section
Name First Middle Last Sex
Niles Deklyn Tonner Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 17, 2018 75 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Elizabethtown Street Address UVM Health Network-ECH
p• Manner of Death n Natural Cause I I Accident Homicide 7 Suicide n Undetermined Pending
Circumstances Investigation
uj Medical Certifier Name Title
G Kelly Vallentine Coroner
Address
Moriah,NY 12960
Death Certificate Filed District Number Register Number
City, Town or Village Town Of Elizabethtown ((�9g
❑Burial Date Cemetery or Crematory
November 19, 2018 Pine View Crematory
❑Entombment Address
0 Cremation , Queensbury, NY
Date Place Removed
Z I I Removal and/or Held
and/or Address
rz Hold
v)
O Date Point of
NI 'Transportation Shipment
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
1019 State Route 9, Schroon Lake, NY 12870
Name of Funeral Firm Making Disposition or to Whom
1--' Remains are Shipped, If Other than Above
2' Address
cc
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/19/18 Registrar of Vital Statistics Cam,,A. ._.0 O
(signature)
District Number i 5 Place Town Of Elizabethtown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p Place of Disposition . U (,e o .—s.
W Date of Disposition it I ZO $ ,u
2 (address)
W
Cl)
O (section) 1 (lot num ) (grave number)
p• Name of Sexton or Person in Charge of Pre ises t A 24.141
Z (p1 ase print)
W' /( A,c
Signature /. Title �1�-irii 1�
C. (over)
DOH-1555(02/2004)