Coyle Jr., Clifford Edwin It 16 -
NEW YORKSTATE DEPARTMENT OF HEALTH Burial- Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Clifford Edwin Coyle Jr Male
Date of Death Age If Veteran of U.S.A es,
11/14/2021 87 Years War or Dates 956
Place of Death Hospital,Institution or
Z City,Town or Village Ticonderoga Town Street Address Elderwood at Ticonderoga
W Manner of DeathUndetermined Pending
G �Natural Cause ❑Accident ❑Homicide El 11 ❑
W Circumstances Investigation
0 Medical Certifier Name ° P"yf
Kristin Mack DO
Address
1019 Wicker St,Ticonderoga Town,New York 12883
Death Certificate Filed Disiliiirber Register Number
City,Town or Village Ticonderoga 1564 57
❑Burial Date Cemetery,Crematory or Facility Name
11/16/2021 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
ZO El Removal Date Place Removed
and/or and/or Held
~ Hold Address
W
0
G. Date Point of
If) Li Transportation Shipment
a- byCommon P
Carrier Destination
Date Cemetery Address
ElDisinterment
Date Cemetery Address
ElReinterment
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
CC
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a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/15/2021 Registrar of Vital Statistics 7 At Thompson(Ek "ircal 47114
(signature)
District Number 1564 Place Ticonderoga, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition II I it I Z' Place of Disposition Vi (it-
i. (address)
2
W
CC (section) J{�� //otnumber) (grave number)
O /i•\1.c1 'Lf(
0 Name of Sexton or Person in Charge Premises p�ease print) /�
Z f -40/ 11 WYL
W Signature Ttle
DOH-1555(07/18)p 1 of 2
PUBLIC HEALTH LAW
r4.
§ 4145. Deaths; burial and removal permits; disposition of remains. 1. 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 aanied 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 shall 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
M
Public Health Law Sec. 4145(2b)
Receipt
1 Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#