Kelly, Roberta Lee 513
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Roberta Lee Kelly Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/15/2022 64 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Whitehall Town Street Address 9863 State Route 4 Route Apt#15,Whitehall Town,New York 12887
WManner of Death Undetermined Pendin
Natural Cause Accident Homicide Suicide g
C.) Circumstances Investigation
W Medical Certifier Name Title
G Jean Hanson PA
Address
325 Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Town Of Whitehall District Number Register Number
City,Town or Village 5766 10
Burial Date Cemetery,Crematory or Facility Name
07/19/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
LIDonation
01Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
a Date Point of
(A Transportation
by Common Shipment
Carrier Destination
Date CemeteryAddress
�Dismterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
a Address
Q
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/19/2022 Registrar of Vital Statistics Patti Gordon(ECectronica1y Signed)
(signature)
District Number 5766 Place Town Of Whitehall
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZDate of Disposition 7 iZl I it Place of Disposition
2 (address)
W
N
CC (section) (lowumber) (grave number)
SName of Sexton or Person in Charge of Premi e 1
Z (plea print)
W Signature Title ` �{Tat
DOH-1555(07/18)p 1 of 2
f v
3,d - +•��sue,. � _.
Public Health Law Sec. 4145(2b)
Receipt
•
Human remains of !` delivered on , 20 ,
1
Pine View Cemetery Representing the funeral home named)on b04l permit
Official Funeral Directors Reg. or License#