Kelley, Sally NEW YORK STATE DEPARTMENT OF HEALTH i A 323
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sally Kelley Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 23, 2012 63 War or Dates
I— Place of Death Hospital, Institution or
' City, Town or Village Queensbury Street Address 82 Main Street
W
W' Manner of Death 1771
Natural Cause Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
,; Circumstances Investigation
CI
Medical Certifier Name Title
MD J MIHINDU,
Address
20 Murray Street Glens Falls, NY 12839
Death Certificate Filed District Number Register Number
City, Town or Village 510
'y
0 Burial Date Cemetery or Crematory
June 26, 2012 Pine View Crematorium
0 Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
and/or Address
. Hold
O Date Point of
flTransportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
111:1Reinterment 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
W
11' Permission is herebygranted to dispose of the human re p r�'iains d scribed bo as indicated.
Date Issued (o_ o..;._10,L Registrar of Vital Statistics � I��t \ '
(signature)
District Number c s--7 Place ikc,.ei.z -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W; Date of Disposition (.(U,112 Place of Disposition �wu144 Crrirettfo r w*-
2 (address)
W
0
r4 (section) II (lot number) ,- (grave number)
pName of Sexton or Person in Charge f PremisesA f�^r��� 3 Cwt��
W . r(please print)
Signature Title Clt '` dt
(over)
DOH-1555 (02/2004)