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Kellet, Helena P NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Helene P.Kellett Female Date of Death Age If Veteran of U.S.Armed Forces, 12/08/2021 96 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Chester Town Warren Street Address 18 Ferris Road,Chester Town Warren, New York 12817 p Manner of Death ©Natural Cause Accident Homicide Suicide 0 Undetermined 0 Pending W V Circumstances Investigation a Medical Certifier Name Title Curtis Gedney MD Address 454 Glen Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Chestertown 5652 21 Burial Date Cemetery,Crematory or Facility Name 12/09/2021 Pine View Crematorium Ej Entombment Address 0 Cremation Queensbury Hamlet,New York Donation Removal Date Place Removed H and/or and/or Held N Hold Address 0 a Date Point of u ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom F.- Remains are Shipped,If Other than Above 2 Address LC W 0' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/09/2021 Registrar of Vital Statistics Mindy Conway(E(ectronicaffySigned) (signature/ District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 12-110114 Place of Disposition s ci�r,_ ',,,f ,,,_- 2 (addr ss) W CO CC (section) n (lot number) (grave number) SName of Sexton or Person in Charge of P ises iil 6 1,-- _ A4il Z ( e print) W Signature t—' Title rat;"�►9/14- DOH-1555(07/18)p 1 of 2 25 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#