Kelly, Richard NEW YORK STATE DEPARTMENT OF HEALTH # ti 5 5
Vital Records Section Burial - Transit Permit
VTR
Name First Middle Last Sex
Richard F. Kelly Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 6,2011 `7 War or Dates
. Place of Death Hospital, Institution or
, City, Town or Village (We-6(4.-A._-- Street Address 7 Woodscape Drive
c' Manner of Death I)/I Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
ui Title
Medical Certifier Name
R; Age a , tikertAt_c m .
Address /OL `itte4, toy t
Death Certificate Filed District Number Register Number
°,, City, Town or Village
❑Burial Date Cemetery or Crematory
❑Entombment November 8, 2011 Pine View Crematorium
Address
11 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
9 and/or Address
F_ Hold
M
0 Date Point of
a.
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
° Permit Issued to Registration Number
.x,,: Name of Funeral Home Regan& Denny Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
. Name of Funeral Firm Making Disposition or to Whom
1 , Remains are Shipped, If Other than Above
E Address
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c `, Permission is hereby granted to dispose of the human remains described above as indicated.
:' Date Issued //-(?-0/41// Registrar of Vital Statistics / 4..t4.a-e ms),, 44/z__
(signature)
District Number ic a, Place n `O� C �.e�� r
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z •
w Date of Disposition tjv, ;Di Nit Place of Disposition 24 V ttv► CoAwc.4 ort uy .
w (address)
co
CC (section) (lot number),- (grave number)
ap Name of Sexton or Person in Charge of Premises 4,:stbfk,r e h nct'I"Z (please print)
W Signature AL, Title (Isc� N{.r
(over)
DOH-1555(02/2004)