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Welch, John P. it I30 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John P Welch Male Date of Death Age If Veteran of U.S.Armed Forces, 12/13/2020 70 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Schroon Town Street Address 16 Breezy Meadows Way,Schroon Town,New York 12870 W p Manner of Death © Natural Cause Accident ❑Homicide 0 Suicide ❑Undetermined Pending 0 Circumstances Investigation W Medical Certifier Name Title Christopher Hoy MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Schroon Lake 1563 11 ❑Burial Date Cemetery,Crematory or Facility Name 12/15/2020 Pine View Crematory 0 Entombment Address ]Cremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held Hold Address 0 d Date Point of U) Li Transportation p by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Edward L Kelly Funeral Home 00519 Address PO Box 548,Schroon Lake,New York 12870 Name of Funeral Firm Making Disposition or to Whom l- Remains are Shipped,If Other than Above 2 Address EC W d Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/14/2020 Registrar of Vital Statistics Patricia Savarie(EtectronicalTy Signed) (signature) District Number 1563 Place Schroon Lake, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit. Z Date of Disposition 12�15'Ito Place of Disposition W (address) W CC (section) 4„.,,,inumberls-pin (grave number) O 0 Name of Sexton or Person in Charge of P emises � L �i7 ,�C� /P/eas printl IL (�=MW�2 Signature Title DOH-1555(07/18)p tot 2 PUBLIC HEALTH LAW, § 4145. Deaths; burial and removal permits; disposition of remains. ti No person in charge of any premises on which interments, cremations or other disposition of the body of a deceased person are made shall inter or permit the interment or other disposition of any body unless it is accompanied by a burial,cremation or transit permit,as provided in this article. 2. (a) The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition before interring or otherwise disposing of the body or shall attach the removal or transit permit to the box containing the body,when shipped by any transportation company,which permit shalt accompany the remains to its destination, where, if within this state, it shall be delivered to the person in charge of the place of burial or other disposition. (b)Any person or other entity owning,operating,managing,or designated to receive the body of a deceased person at a place of burial, cremation, or other final disposition in this state, who receives the body of a deceased person, shall provide a receipt for the body to the funeral director, undertaker or registered resident who delivered such body. Each receipt shall(i) be endorsed by both such person and the funeral director,undertaker or registered resident, (ii) indicate the date the body was delivered, (iii) include the name of the funeral director, undertaker or registered resident delivering the body and the registration number of such funeral director, undertaker or registered resident, (iv) include the name of the registered funeral firm the funeral director,undertaker or registered resident represents,(v) include the name of the deceased person as it appears on the burial,cremation, or transit permit, and (vi) include the name of the owner, operator, manager, or person in charge of the place of burial,cremation, or other final disposition who received the body of the deceased person.A copy of such receipt shall be retained by the owner,operator,manager,or person in charge of the place of burial, cremation, or other final disposition for a period of not less than four years, and shall be made available for inspection by the division of cemeteries during normal business hours.The original copy of every such receipt shall be retained by the licensed funeral firm for a period of not less than four years pursuant to the rules and regulations of the department governing the maintenance of records. 3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment, or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of interment,cremation or other disposition. 4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the funeral director or undertaker shall (a) sign the burial or removal permit,giving the date of burial; (b) write across the face of the permit the words "No person in charge; "and (c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is located. 5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or otherwise disposed of on the premises under his charge,in each case stating the name of each deceased person,place of death, date of burial or disposal, and name and address of the funeral director or undertaker,which record shall at all time be open to official inspection. DOH-1555(07/18)p 2 of 2 Public Health Law Sec. 4145(2b) ' " 014295 Receipt Human remains of delivered on , 20 I Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#