Kelly, Sandra NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Berrrtie 5,1,4 i L. Kelly Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/04/2014 68 years War or Dates
}- Place of Death Hospital, Institution or
City, Town f�rX\jill tXX Glens Falls Street Address Glens Falls Hospital
Iz Manner of Death Lim Natural Cause El Accident LI Homicide El Suicide El Undetermined Pending
LEI Circumstances 'investigation
W Medical Certifier Name Title
Q Timnthy F Murphy Coroner
Address
52 Haviland Ave Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TomuityiligmlwAXX Glens Falls 5601 62
El Burial Date Cemetery or Crematory
❑Entombment 02/10/2014 Pineview Cemetery
Address
❑C,yernation Queensbury. N Y
Date Place Removed
Z Removal and/or Held
2❑and/or Address
tt Hold
U)
0 Date Point of
CL
❑Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home, Inc. 00448
Address
7 Sherman Ave. Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
la
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/07/2014 Registrar of Vital Statistics W
(signatur
District Number 5601 Place Glens Falls i Al U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k WLt Date of Disposition a(iiIN Place of Disposition .,��,, atto �r n40•.
(address)
i<U
IC (section) t number) e�° (grave number)
O.
Name of Sexton or Person in harge of Pr mises it-AriseJl%�r401
2 (pleaprint)
9
Si nature ' L Title Cilt 0IVCOK
(over)
DOH-1555 (02/2004)