Kelly, Robert NEW YORK STATE DEPARTMENT OF HEALTH i 1 If �0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert J. Kelly Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 8,2012 74 War or Dates
>;; Place of Death Hospital, Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident 0 Homicide Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Dr Hoffman,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Vumber
City, Town or Village Glens Falls,NY 5601 1
❑Burial Date Cemetery or Crematory
❑Entombment September 10, 2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO El Removal and/or Held
and/or Address
E Hold
N
O Date Point of
5 0 Transportation Shipment
a by Common Destination
Carrier
Ei
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
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 remains described above a, indicated.
Date Issued 9. ) / 0 j/? Registrar of Vital Statistics G`1e...ki.4-,..44
(signatu
District Number 5601 Place Glens Falls,NY p q 61
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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w Date of Disposition 1_10-IZ Place of Disposition i',.J,0q� Co-4or,l,►..
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pIX (section) - (lot nurpber) (grave number)
Name of Sexton or Person in Charge of Premises 4tiyt+. ,.,,,(}
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W Signature ( Title CnAi'Ot1.
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DOH-1555(02/2004)