Kelly, Mark i
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section # Burial - Transit Permit
it
Name First Middle Last Sex
Mark J. Kelly Male
Date of Death Age If Veteran of U.S.Armed Forces,
August 17, 2011 53 War or Dates No
I-. Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address Albany Medical Center
Manner of Death Natural ❑ Undetermined ❑ Pending
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide Circumstances Investigation
W' Medical Certifier Name Title
Ca Lance Sullenberger MD
Address
43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1540
Date Cemetery or Crematory
® Burial August 22, 2011 Pine View Crematory
El Entombment
❑ Cremation Address
Queensbury, NY
Date Place Removed
Z' Removal and/or Held
O ❑ and/or Address
H Hold
Cl,
(Q Date Point of
Q Transportation Shipment
Cl) ❑ By Common
p Carrier Destination
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street, Warrensburg, NY 12885
H' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IZ
W'
Q- Permission is hereby granted to dispose of the human remains described above indicated. G
Date August 18, 2011 Registrar of Vital Statistics
Issued (signature se
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this/�permit on:
Z Date of Disposition 41--? 1-t( Place of Disposition fM If ) liV+eh`640ti
U.1 (address)
w
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cc (section) (lot number) (grave number)
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Q
Z' Name of Sexton or Person in Charge of Premises t fif' J a N+si bi"
w r i(please print)
Signature di- Title C12CMATO .
(over)
DOH-1555 (02/2004)