Loading...
Kelley, Henry NEW YORK STATE DEPARTMENT OF HEALTH 3Vital Records Section Burial - Transit Permit 1,:: 1 ' "' Name First Middle Last Sex Henry Eugene Kelley Male Date of Death Age If Veteran of U.S. Armed Forces, May 30, 2016 72 War or Dates F- Place of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death a Natural Cause ❑ Accident ❑ Homicide 1=1 Suicide ❑ Undetermined `--1 Pending CircumstancesInvestigation W'' Medical Certifier Name Title CI Marvin Davidowitz, M.D Address 100 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village a77 ❑Burial Date Cemetery or Crematory June 1, 2016 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z El Removal and/or Held and/or Address H Hold Date Point of a ❑Transportation Shipment 0) by Common Destination d. Carrier Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom F-- Remains are Shipped, If Other than Above 2 Address CC C' Permission is hereb ranted to dispose of the human remains descrdbov s i 1 ed. Date Issued 06 Di 29/6 Registrar of Vital Statistics // (signature) District Number SW/ Place to% A<Z, /V Y . I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 06/01/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) w 0) Ce (section) dpi-tzt.v. (lot number) /� (grave number) 0 Name of Sexton or Person in Charg of Premises --�104/4- z (pase print) W Signature GEC ` Title Ithhteta (over) DOH-1555 (02/2004)