Knowlton, Deborah 92
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Deborah Ann Knowlton Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/03/2017 64 Years War or Dates
E— Place of Death Hospital, Institution or
W City, Town or Village Plattsburgh Street Address Champlain Valley Physicians Hospital Medical Ctr
• Manner of Death a Natural Cause El Accident El Homicide El Suicide El Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
Andrei Cepoi MD
Address
75 Beekman St,Plattsburgh,New York 12901
Death Certificate Filed District Number Register Number
City, Town or Village Plattsburgh 0901 526
El Burial Date Cemetery or Crematory
12/05/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z�Removal and/or Held
2 and/or Address
- Hold
O Date Point of
taA Q Transportation Shipment
G by Common Destination
Carrier
El
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 US Route 9 PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
OC
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/04/2017 Registrar of Vital Statistics syczia GParrotu cEfectronicalfysigned
(signature)
District Number 0901 Place Plattsburgh, 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 /z/ S.Jo Place of Disposition 1' VJ AM-15")
(address)
W
N
(section) (jot number (grave number)
C) Name of Sexton or Person in Ch rge of Prem. s /lM ^•1'�
Z (p se pn�J �, �
▪ Signature Title I%W V'' ..
(over)
DOH-1555 (02/2004)