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Kelly, Deborah A s_ .it gvp NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Deborah A.Kelly Female Date of Death Age If Veteran of U.S.Armed Forces, 10/03/2021 57 Years War or Dates ZZ Place of Death Hospital,Institution or ILI City,Town or Village Lake George Town Street Address 88 Bloody Pond Road,Lake George Town,New York 12845 p Manner of Death ©Natural Cause 0 Accident El Homicide 0 Suicide 1=1 Undetermined 1=1 Pending W U Circumstances Investigation Ui Medical Certifier Name Title ID Connie Goedert Coroner Address 1400 St Route 9, Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Lake George 5651 19 Burial Date Cemetery,Crematory or Facility Name 10/07/2021 Pine View Crematory 0 Entombment Address X❑Cremation Queensbury Town,New York 0 Donation Removal Date Place Removed F, and/or and/or Held N Hold Address 0 O. co Li Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above N Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/06/2021 Registrar of Vital Statistics Patricia c,9KcKinney Schuster(ElectronicaCCy Signed) (signature) District Number 5651 Place Lake George, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ILIDate of Disposition /U'(G 1'1 Place of Disposition 1 ,,/ (►-Adr...—_ (address) W (I) CC (section) (lot number) (grave number) Name of Sexton or Person in Cha At., L4t ,. wat:T Z of Premises /pliese print/ W Signature Title � ��� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 3 1 5 2 o 7 Receipt i , Human remains of .T`-' .. ' / delivered on , 20 t f , i f, r/ ."-- Pine View Cemetery Representing the funeral home named onAur4a1 permit •Official Funeral Directors Reg.or License#