Kelly, Richard (2) 11 yc"
NEW YORK STATE DEPARTMENT OF HEALTH \-----1 Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Kelly Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/04/2022 83 Years War or Dates
F. Place of Death Hospital,Institution or
Z City,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing
W
p Manner of Death �NaturalCause tHomicide []Suicide nUndetermined ❑Pending
II I(Circumstances Investigation
WMedical Certifier Name Title
CI Thomas Kandora MD
Address
17 Madison St,Granville Village,New York 12832
Death Certificate Filed Village Of Granville district Number Register Number
City,Town or Village 5725 28
riBurial Date Cemetery,Crematory or Facility Name
07/12/2022 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
i Hold Address
N
0
0- Date Point of
(/)OTransportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
riDate Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
Address
CC
W
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/12/2022 Registrar of Vital Statistics Richard Wpberts(E(ectronical(y Signed)
(signature)
District Number 5725 Place Village Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F— rJ
Z Date of Disposition 1 iM Ilt Place of Disposition FAL-. taut--'
W
M (address)
LU
CCCC (section) ail (lot num (grave number)
0 Name of Sexton or Person in Charge of Pr .ses i/{a M L ����fJl�w.il>1
z (please print)/�
LU Signature C—� _ Title.,-- [ i'1'� ��
DOH-1555(07/18)p t of 2
1
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#