Loading...
Kelly, Kathie Louise 4 (VO— N EW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kathie Louise Kelly Female Date of Death Age If Veteran of U.S.Armed Forces, 11/26/2020 61 Years War or Dates 1980-2000 ZPlace of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address 10 Spring Street,Glens Falls,New York 12801 p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending UJ C.) Circumstances Investigation 0ILI Medical Certifier Name Title John Stoutenburg MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 543 ❑Burial Date Cemetery,Crematory or Facility Name 12/01/2020 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,Warren,New York ❑Donation ZEl Removal Date Place Removed p and/or and/or Held N Hold Address 0 IL 1-1 Date Point of Cl) ❑Transportation 5 by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address Ilr W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/01/2020 Registrar of Vital Statistics R9bertAndfrew Curtis(Efectronica1ty Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition 12 f Z Ito Place of Disposition -4?-1- ZA----- 2 (address) W N CC (sect/on) /hr //000tnumber /gravenumber/ Nameof Sexton or Person in Charge of P mises , µft Z0 /P/ea e print/ W /Signature Title IWAtitv4 DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) , ,, •, Receipt Human remains of delivered on , 20 { Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#