Stickney, Charles K NEW YORK STATE DEPARTMENT OF ItEALTH . Burial- Tra�nqstit Permit
Bureau of Vital Records
Name First Middle Last Sex
Charles K Stickney Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/18/2021 82 Years War or Dates 1961-1963
Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
W Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
W Suzanne Rayeski DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 458
ElBurial Date Cemetery,Crematory or Facility Name
08/23/2021 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
ElDonation
Removal Date Place Removed
and/or and/or Held
Hold Address
0
n• Date Point of
V) J Transportation
6 by Common Shipment
Carrier Destination
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
f.. Remains are Shipped,If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/19/2021 Registrar of Vital Statistics Join Paid rFranck(Electmnicaltr'Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p
Z Date of Disposition 9-/ q Place of Disposition C:j e o
ILJ
laddresof
W
CCCC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charg f Premises ' P!/e0/1 41ted
(please print)
W Signature Title
DOH-1555(07/18)p 1 of 2
0 0 5
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#