Rice, Ernest R LF # 3-711
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Perrntt
Bureau of Vital Records
Name First Middle Last Sex
Ernest R Rice Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/03/2022 77 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Schroon Town Street Address 1083 Main Street,Schroon Town,New York 12870
`p Manner of Death II Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
ILI Medical Certifier Name Title
Melanie Duerr NP
Address j
47 Tom Phelps Lane,Mineville Hamlet,New York 12996
Death Certificate Filed Town Of Schroon District Number Register Number
City,Town or Village 1563 5
Burial Date Cemetery,Crematory or Facility Name
05/05/2022 Pine View Crematory
Entombment Address
DCremation Queensbury Town,New York
Donation
ZZ❑Removal Date Place Removed
and/or and/or Held
Hold Address
0
O. Date Point of
N Transportation
5 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
EiReinterment 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
1.. Remains are Shipped,If Other than Above
S Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/04/2022 Registrar of Vital Statistics Patricia Savarie(E(ectronicaCCy Signed)
(signature/
District Number 1563 Place Town Of Schroon
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition =3;/.O1 2
Z Place of Disposition , ,fie t'.u.) C't,X•rq,g,-4
2 (address)
W
Vl
(section) llgt nu7er) (grave number)
SName of Sexton or Person in Charge of mi ,�►y'•11v.1) (,gf/t
Z / (please print)
W Signature ! Title OtWev '4'---
DOH-1555(o7/18)p t of 2 fff
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#