Kelly, Bernice -73
NEW YORK STATE DEPARTMENT OF HEALTH ff 5
Vital Records Section . ts Burial - Transit Permit
Name First Middle Last Sex
Bernice Kelly Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 26, 2012 81 War or Dates
ZPlace of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death X❑ Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
d Suzanne Blood, M.D. Dr.
Address
14 Manor Drive Queensbury, NY 12804
Death Certificate Filed District Numbers Reg it r Number
City, Town or Village Q�, 2 (�1
❑Burial Date Cemetery or Crematory
October 29, 2012 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
O ❑ Removal and/or Held
and/or Address
Hold
f1) Date Point of
a0 Transportation Shipment
0) by Common Destination
E Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
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
b Remains are Shipped, If Other than Above
2 Address
W''
L. Permission is hereby granted to dispose of the human remains describ b e ind'
Date Issued /O/2 /201L Registrar of Vital Statistics
(signature)
District Number `j601 Place of&. 2„o AA, /0'
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
of Date of Disposition 10-ri-i1 Place of Disposition 4?,4tL4J (, tarj�
2 (address)
W
CO (section) (lot number'' (grave number)
0- Name of Sexton • Person in Ch ge of Premises At'1.111..
`3 i"'4'1
a (please print)
l
W Signature u't e— Title r Ag
(over)
DOH-1555 (02/2004)