Connelly, Gary (9n �/
NEW YORK STATE DEPARTMENT OF HEALtH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary Connelly Male
ni Date of Death Age If Veteran of U.S. Armed Forces,
OR/92/2016 65 years War or Dates 1970-1973
1-- Place of Death Hospital, Institution or
City, To X Street Address 68 Alexander J Ave.; Mechanicville, N Y 12118
i4 � C Mechanicville
Manner of Death❑I�latural Cause ❑Accident 0 Homicide 0 Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
tgi Medical Certifier Name Title
Stephen Kineke M. D.
Address
1783 Route 9, Clifton Park, N. Y. 12065
Death Certificate Filed District Number Register Number
City, MNlx9nVilifi9CXX Mechanicville 4523 14
['Burial Date Cemetery or Crematory
❑Entombment 08/23/2016 Pine View Crematory
Ai Address
iiiii❑remation Queensbury, New York
Date Place Removed
g.... n❑Removal and/or Held
rt and/or Address
t7 Hold
? Date Point of
0 Li Transportation Shipment
Gil by Common Destination
Carrier
❑Disinterment Date Cemetery Address
': ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc. 00364
Address
402 Maple Ave.; Saratoga Springs, N Y 12866
iiig Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
re
Permission is hereby granted to dispose of the human re ains described ab ye indicated.
-
IN Date Issued 08/22/2016 Registrar of Vital Statistics( � .(' uci f(/
(signature)
District Number 4523 Place Mechanicville
'.: :> I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui• Date of Disposition e 2-rpeP Place of Disposition Pd2E Wet) G/eirt y
2 (address`
W
CC (section) /got number) (grave number)
• Name of Sexton or P rso in Charge of Premises �b' ���"TCJ�
2 (please print)
itil
Ti Signature Title C.e..-/n
(over)
DOH-1555 (02/2004)