St. John, Katherine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Katherine A.St.John Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/09/2018 71 Years War or Dates
Place of Death
Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death gi Natural Cause D Accident El Homicide D Suicide riUndetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
Farhana Kamal MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
fg City, Town or Village Glens Falls 5601 229
DBurial Date Cemetery or Crematory
05/14/2018 Pineview Crematorium
It' Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Z ❑Removal and/or Held
and/or Address
t Hold
V Date Point of
❑Transportation Shipment
L by Common Destination
Carrier
Q Disinterment
nv Date Cemetery Address
❑Reinterment Date Cemetery Address
1 Permit Issued to Registration Number
'-11 Name of Funeral Home Densmore Funeral Home Inc 00448
. Address
7 Sherman Ave,Corinth,New York 12822
ii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
E Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
:
_'
Date Issued 05/11/2018 Registrar of Vital Statistics RodertA Curtis(ECectronica(CySigned)
:. (signature)
„a District Number 5601 Place Glens Falls, New York
i- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
at Date of Disposition Slit lit Place of Disposition ?hJJ.l,. Air'v./
W (address)
CO
M (section) (lot umber) (grave number)
0 Name of Sexton or Person in Charge of Pr ises CpL �6vat
2 (pleas print)
Signature Title li/NiA/1
(over)
DOH-1555 (02/2004)