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Courville, Kelly 3©t NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Kelly Marie Courville Female 3 Date of Death Age If Veteran of U.S.Armed Forces, 1'= 4/22/2015 50 War or Dates 1r i-= Place of Death Hospital, Institution or Z City,Ro(�atdci��cxwlsig�c Gl ens Falls Street Address Glens Falls Hospital Iiip Manner of Death®Natural Cause 0 Accident 0 Homicide El Suicide n Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title q Suzanne M. Rayeski M.D. E Address 100 Park St. Glens Falls N.Y. 12801 Death Certificate Filed District Number Register Number City,IMP XiiIIIR Glens Falls 5601 G 1(4 ❑Burial Date Cemetery or Crematory 4/27/2015 Pineview Crematorium ❑Entombment Address I ]Cremation 21 Quaker Rd. Queensbuey N.Y. 12801 Date Place Removed Z Removal and/or Held 2❑and/or Address E= Hold Cl) O Date Point of N Q Transportation Shipment O by Common Destination Carrier Q Disinterment Date Cemetery Address ▪ Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Radl off Funeral Home Inc. 1425 Address 136 Warren Glens Falls N.Y. 12801 Name of Funeral Firm Making Disposition or to Whom !44 Remains are Shipped, If Other than Above 2 Address CC W aPermission is hereby granted to dispose of the human retains de , ibed abov- as indica'-d. Date Issued (4,N I c. Registrar of Vital Statistics ,/t ! %� // / (si nature) 11 District Number Jr Place .---°a,e---/t—,!) �� ( AI certify that the remains of the decedent identified above wer- disposed of in accordance ith this permit on: Z - W Date of Disposition N/nIlc Place of Disposition -?v,Use rJCd"N.- 2 (address) W N (C (section) (lot fi ber) (grave number) p C Name of Sexton or Person in Charg of Premises L„•' �tM ci- Z (please Tint) W Signature Title C(t6"t r4 i trt (over) DOH-1555 (02/2004)