Kelly, June 74
NEW YORK STATE DEPARTMENT OF HEALTH t t
11
Vital Records Section Burial - Transit Perm t
'elName First Middle Last Sex
June Marilyn Kelly Female
'l Date of Death Age ' If Veteran of U.S.Armed Forces,
44 10/09/2017 80 Years War or Dates
} Place of Death Hospital, Institution or
W City, Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
p Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
j i Medical Certifier Name Title
O Jennifer Hayes MD
�: Address
4573 State Route 40,Argyle Town,New York 12809
ry Death Certificate Filed District Number Register Number
City, Town or Village Argyle 5750 24
__e7-7-`1 El Burial Date Cemetery or Crematory
10/16/2017 Pine View Crematory
a�
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation _ Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
t. Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 10/12/2017 Registrar of Vital Statistics SkelleyMckernon E1 ctronicallySigned
(signature)
District Number 5750 Place Argyle, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tt
WDate of Disposition /b f f if) Place of Disposition r j,,,, �,.w„rdP,ti,
1 (address)
Cl)
(section) (lot nlrmber) C (grave number)
Q Name of Sexton or Person in Charge of Premises Gil r)ft ',niwii
z (pha 0 4
se print)
Signature ILI
a i/6 Title 112(i'r rtiDil---
(over)
DOH-1555 (02/2004)