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Kelley, Clarence NEW YORK STATE DEPARTMENT OF HEALTH � ��3 Vital Records Section Burial - Transit Permit 3 Name First Middle Last Sex Clarence Martin Kelley Male Date of Death Age If Veteran of U.S. Armed Forces, December 27, 2016 83 War or Dates E Place,call-=th Hospital, Institution or W= City, mown %r Village Kingsbury Street Address 16 Country Rte 41 Mann- •_ Death• X Natural Cause Accident Homicide: Suicide Undetermined Pending Circumstances Investigation W' Medical Certifier ' Name Title Cal- Gerald F Abess MD, Address 3 Irongate Ctr. Glens Falls, NY 12801 , Death ificate Filed x District Number Register Number :4 City own or Village i n C,�S b (Af 1r 7 6 j. /O Ai❑Burial Date J Cemetery or Crematory December 29, 2016 Pine View Crematorium 0 Entombment Address zeN©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of 0.E Transportation Shipment :62 by Common Destination .15 Carrier ❑ Disinterment Date Cemetery Address It Reinterment Date Cemetery Address ai Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 fit 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 'j, Remains are Shipped, If Other than Above Address - t . Permission is hereby g dispose to dis ose of the human remains described above as indicated. U Date Issued j)_/a C, u y/4, Registrar of Vital Statistics Q,c.-,` Cc ei- c,,P.r, f (signature) District Number - 7 G„4 Place jpct/n al /6 kf_4i4): , J I certify that the remains of the decedent identified above were disposed of in Accordance with this permit on: ',izt- riale_m re t4)6/,,,,,,,,,,,47 Date of Disposition 12/ 2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W (section) (lot number) (grave number) ty Name of Sexton or rso in Charge of Premises �../,-A.��t ("a/m Q e.,4 e (please print) Signature Title rd,% D� (over) DOH-1555 (02/2004)