Kelly, Loretta �`, c 3 v
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:3 Name First Middle Last Sex
Loretta M. Kelly Female
Date of Death Age If Veteran of U.S. Armed Forces,
=g°x December 23,2016 82 War or Dates
Place of Death Hospital, InstitutiorWhrren Center For Rehabilitation And
j
City, Town or Village Queensbury Street Address Nursing
:0. Manner of Death I XI Natural Cause Accident I I Homicide Suicide Undetermined Pending
—Circumstances —Investigation
lit Medical Certifier Name
Title
, Roslyn Socolof
Address
7;9 Carey Rd.,Queensbury,NY 12804
Death Certificate Filed District Number l''egi�tNumber
i City, Town or Village Queensbury 5657 I
❑Burial Date Cemetery or Crematory
❑Entombment December 27,2016 Pine View Crematory
Address
E1 Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N I a. I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
G Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
,, Permission is hereby granted to dispose of the human -e ins described bove as indicated.
Date Issued 1 '-1 bOK.3 Registrar of Vital Statistics -ti (L -''', ,
(signature)
-_t District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition /2%29p6 Place of Disposition /-�/�L�v1 & C�fe�1 a, V
W / (address)
rn
Q (section) J fiat number) (grave number)
ZName of Sexton jr Person in Charge of Premises t,1,1 ra v( r1ayvn C._Glie
(please print)
W Signature �� Title U fdvric4.�csr
(over)
DOH-1555 (02/2004)