Kelley, Jennie Et to) 7
NEW YORK STATE DEPARTMENT OF HEALTH ! v
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jennie Helen Kelley Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 18, 2014 90 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death 1 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W_' Medical Certifier Name Title
CI Frances Bollinger MD,
Address
161 Carey Rd Queensbury, NY 12804
Death Certificate Filed District Number Re9 ist 1 ber
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
October 21, 2014 Pine View Crematorium
:,❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z 0 Removal and/or Held
• and/or Address
F. Hold
O Date Point of
a:❑Transportation Shipment
0= by Common Destination
C] Carrier
Date Cemetery Address
❑ 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
F- Remains are Shipped, If Other than Above
2'' Address
t
Ui
Permission is hereby ranted to dispose of the human remains describ dab vee in d.
Date Issued /O a/ d,0/S< Registrar of Vital Statistics �� 1�(
(signature)
District Number 5601 Place C/e�_fr /f,,�l/2 /
FI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W' Date of Disposition 10/21/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
W (section) t number) (grave number)
0 Name of Sexton or Pers n in Charge of Premises ��s r st4v it
Z ( (pleate print)
W' 'e��
Signature - Title Ciyrm t
9
(over)
DOH-1555 (02/2004)