Clark, Kimberley k s Gao 21
NEW YORK STATE DEPARTMENT OF HEA`LT$t
Vital Records Section Burial - Transit Permit
; Name First Kimberly Middle Lynn Last Clark Sex F
Date of Death Age If Veteran of U.S. Armed Forces
January 11 , 2006 26 War or Dates NO
}i Place of Death Albany Hospital, Institution or
St . Peter ' s Hospital
CCTown or Village Street Address
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t0Manner of Death®Natural Cause 0 Accident ❑Homicide 0 Suicide ❑Undetermined El❑Pending
Circumstances Investigation
iu Medical Certifier Name Title
T\()NO VI ti A,e,\con
Address
317 S. Manning Blvd. , Albany, NY 12208
Death Certificate Filed Albany District Number Register Number
pCi Town or Village 101 70
Burial
Date 1/12/2006 Cemetery orCrematortine View Crematory
['Entombment Address Pine View Crematory
remation Quaker Road Queensbury, NY 12804
Date Place Removed
Removal and/or Held
9 and/or Address F;
VI
o Date Point of
tip. Ei Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to M. B. Kilmer Funeral Home Recq 1rati n Number
Name of Funeral Home
Addrebs2 Broadway Fort Edward , NY 12828
Name of Funeral Firm Making Disposition or to Whom
10- Remains are Shipped, If Other than Above
2 Address
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CC` Permission is hereby granted to dispose of the human re ins described Above s indicate . 1
Date IssuedJan. 11 , 2006 Registrar of Vital Statistics z
►�
(signature) C _ .
District Number 101 Place City of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5 Date of Disposition i-/2 d C' Place of Disposition fl i'Ng//j c(,4) Cd R vt4t ai t t)ni
2 (address)
W
CC (section) /� (lot number) (grave number)
Name of Sexton or Person in Charge of Premises GyV 1l-' .. (rR AXt -1-'--
z (please print)
> Signature & `_ �p,24V Title C.,it �L ✓� d 2
(over)
DOH-1555 (02/2004)