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Kelley, Darrin NEW YORK STATE DEPARTMENT OF HEALTH r Vital Records Section Burial - Transit Permit Name First Middle Last Sex Darrin Richard Kelley Male V,, Date of Death Age If Veteran of U.S. Armed Forces, April 30, 2017 55 War or Dates i, Place of Death Hospital, Institution or ` City, Town or Village Glens Falls Street Address Glens Falls Hospital Q M• anner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending ❑ ❑ ❑ ❑ ❑ ❑ Circumstances Investigation 1W M• edical Certifier Name Title Cr Address /oo Mel- Sf Gk /f 'V /? / Death Certificate Filed District Number d Register Number p!rat, City, Town or Village y ❑Burial Date Cemetery or Crematory May 3, 2017 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal , and/or Held and/or Address i.., Hold Pine View Crematorium CO' Date Point of ❑Transportation Shipment 0 by Common Destination C Carrier -; Li Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number • Name of Funeral Home Carleton Funeral Home, Inc. 00281 t--Fi A• ddress Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 141, Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above A• ddress CC; grz, Permission is her by ranted to dispose of the human re ains described a, •ve as i • . r d. Date Issued ® /5 ��U/� Registrar of Vital Statistics 4% A `A.' X�j(signature) District Number e/ Place t�.7 '��_ I certify that the remains of the decedent identified above wer- disposed of in accordance with this permit on: ii—£ ut Date of Disposition 05/03/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) w ct?; (section) (lot number)f. (grave number) �� Name of Sexton or Person in Charge of Premises lib;,, 3 w' i fr z ( lease print) 14!,' Signature U� n Title 1(IMAI:kr (over) DOH-1555 (02/2004)