Kelly, Candace • t. it 11s
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Candace Kelly Female
Date of Death Age If Veteran of U.S. Armed Forces,
9/25/2018 _ _ 67 War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village Queensbury,NY Street Address 3 Mannis Road
pManner of Death ["I Natural Cause n Accident _Homicide n Suicide n Undetermined Pending
VCircumstances Investigation
111 C Medical ifier Name Title
Ad ress v
Death Certificate Filed '` District Number Register Number
City, Town or Village Queensbury,NY 5657 (341-
❑Burial Date Cemetery or Crematory
October 2, 2018 Pine View Crematorium
❑Entombment Address
Q Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
E Hold
N
O Date Point of
Wn Transportation _ Shipment
p by Common Destination
Carrier
Disinterment Date 1 Cemetery Address
[-I Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
2 Address
CL
Permission i(( �1 (Osl1hereby granted��ny to dispose of the human re a s e ov dicated.
Date Issued "1— " Registrar of Vital Statistics '7
(signatur
District Number 1516 !Place 1p k,t.,M
I certify that the remains of the decedent identified above w r disposed of in accordance ' thi ermit on:
uijo Date of Disposition f y(1g Place of Disposition ,i
W (address)
CO
0 (section) (lot tuber) (grave number)
p Name of Sexton or Person in Charge of Premises - tre M/,- �ivn4G`
Z (please pint)JSignature Title (over)
DOH-1555(02/2004)