Kelley, Richard NEW YORK STATE DEPARTMENT OF HEALTH J UL/
• I. Burial - Transit Permit
Vital Records Section
Name First •
Middle Last Sex
Richard Kelley Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 29, 2013 39 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Granville Street Address Mettowee River
W; Manner of Death❑ Natural Cause 0 Accident El Homicide Suicide riUndetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
Max Crossman MD,
Address
North St. Granville, NY 12832
Death Certificate Filed District Number Register Number
Cit<Townjbr Village G'RANV(LAX 5 'T S( 3 S
❑Burial Date Cemetery or Crematory
July 5, 2013 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z' Removal and/or Held
and/or Address
F. Hold
CO Date Point of
Transportation Shipment
(0 by Common Destination
i I Carrier
LiDisinterment Date Cemetery Address
Reinterment 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
0" Permission is hereby granted to dispose of the human remains described above as indicated.������""
Date Issued 07 jotor Registrar of Vital Statistics ?---wylY„.-va-ez_)-Y'0AteXXx
(signatrre)
District Number CI$r<, Place — "Own) O F 6-1-,4tJU U..
I certify that the remains of the decedent identified above were disposed of in accord nce with this permit on:
Date of Disposition 1 �j3 Place of Disposition r
W p � I P
2 (address)
W
CO
IX (section) (lot numbe (grave number)
0 Name of Sexton or Person ' Charge of Pr mises ro P -Gti "
(please print)
W Signature �-- Title (Mt/Wit-
(over)
DOH-1555 (02/2004)