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Stark, Kelly J
r, ; 73/ • NEW YORKSTATE DEPARTMENT OF HEALTH .-- Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kelly J Stark Female Date of Death Age If Veteran of U.S.Armed Forces, 09/09/2023 52 Years War or Dates E Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 31 Sweet Road,Queensbury Town,New York 12804 Ili p Manner of Death Z Natural Cause Accident ❑Homicide Suicide Undetermined n Pending Circumstances ' IInvestigation W Medical Certifier Name Title CI Jennifer Stratton MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 143 Burial Date Cemetery,Crematory or Facility Name 09/11/2023 Pineview Crematory Entombment — Address ©Cremation Queensbury Town,New York ❑Donation Z❑Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Date Point of Cl) Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address EReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom 1.- Remains are Shipped,If Other than Above 5 Address Et Ui a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/11/2023 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ZW Date of Disposition q I)Z Z?l Place of Disposition ( ...._ &— ad ress/ W NCC (section) iot number/ C (grave number) ra �-�M i it g Name of Sexton or Person in Charge of P • s � n Z (pleas print) ^� W Signature Title / I ...E DOH-1555(07/18)p t of 2 I > . 1 1 7 2 P 0 Public Health Law Sec. 4145(2b) 0, Receipt i !1 . ( ' 1,'"\ ..,.Human remains of ,'"',/ -- delivered on , . , 20 1 .., .,. ....--------.— ..........— ,-,------- ---- c://,...-,' '17.---------. .. ii lie View Cemetery Representing the funeral home named 9n burial permit Official Funeral Directors Reg.or License#