Kelly Jr, Francis t
NEW YORK STATE DEPARTMENT OF HEALTH ar
Vital Records Section Burial - Transit rermit
'~i" Name First Middle Last Sex
§? ; Francis Edmund Kelly,Jr. Male
:iieDate of Death Age If Veteran of U.S. Armed Forces,
'r'�ti June 28,2016 86 War or Dates 1953- 1955
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
1 Medical Certifier Name Title
William Cleaver
'° Address
'a::: 100 Park Street,Glens Falls,NY 12801
r-: Death Certificate Filed District Number Register Number
:: . 333
:: City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
El Entombment June 29, 2016 Pine View Crematorium
Address
0 Cremation 21Quaker Road, Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
'. Address
ti 407 Bay Road, Queensbury, NY 12804
q Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
rr:: Permission is hereby granted to dispose of the human remains described above as indicated.
•ex Date Issued 6 / 2_q / 16 Registrar of Vital Statistics �; Gl y--1----QAA' A
::'rJ
,: (signatur
�. ? District Number 5601 Place Glens Falls iv
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 413b 116 Place of Disposition 40‘..., ,,,�,cJtt /
2 (address)` . v�_
W'
N
CL (section) pot num¢er) (grave number)
Z Name of Sexton or Person in Charge of Premises A}rl, �`�
f (please pant)
W Signature -47.7Title CjiVMV1-
(over)
DOH-1555(02/2004)