Kellerman, Jerrilyn f # y0
NEW YORK STATE DEPARTMENT OF HEATH
Vital Records Section Burial - Transit Permit
rjr Name First Middle Last Sex
4 Jerrilyn A.Kellerman Female
Date of Death Age If Veteran of U.S.Armed Forces,
vi 06/04/2018 70 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga springs Street Address Saratoga Hospital
Manner of Death X❑Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tit Medical Certifier Name Title
James Corwin MD
Address
ii-', 211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 312
.' ❑Burial Date Cemetery or Crematory
06/08/2018 Pine View Crematory
❑Entombment
Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
Nor by Common Destination
t-
Carrier
_, ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
- ' 53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
6
icti
ri Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/05/2018 Registrar of Vital Statistics John'P�Franck(cEfectronicallySigned)
-" (signature)
District Number Place
4501 Saratoga Springs, New York
`= I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 4 J 111i i Place of Disposition fL Li✓(adr,f,,,....\
s)
la
1 (section) / umber) (grave number)
aName of Sexton or Person in Charge of remises (( , ��'"'iJ
W
�, (pleasnt)
Signature - l Title (Pt"'iiRA
(over)
DOH-1555 (02/2004)