Derusha, Karen sue NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Karen Sue Derusha Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/26/2019 61 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Mannerof Death Undetermined Pending
G ❑X Natural Cause Accident Homicide ❑Suicide g
W Circumstances Investigation
W Medical Certifier Name Title
Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Vitt a a Glens Falls 5601 513
Burial Date Cemetery,Crematory or Facility Name
11/29/2019 Pine View Crematory
Entombment Address
aCremation Queensbury Town,New York
Donation
z ❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
a Date Point of
N ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
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
t= Remains are Shipped,If Other than Above
2 Address
cc
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/29/2019 Registrar of Vital Statistics kAert ndrew('urtrs(E&trnnr?affySorwd)
/signature/
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
W Date of Disposition 1117-9114 Place of Disposition
LU (address)
W
N /sedan/ /la umber/ (grave number/
8 Name of Sexton or Person in Cha of Premis s
Z /please pri t)
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013114
Receipt
Human remains of *` "��` delivered on `�, ' s , 20
l
Pide View Cemetery Representing:the funeral home named on burial permit
Official Funeral Directors Reg.or License#