Cooper, Kathryn Patricia A- 10'3®
NEW YORKSTATE DEPARTMENT OF HEALTH w - Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kathryn Patricia Cooper Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/01/2020 87 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
W Manner of DeathPending
0 Natural Cause �Accident �Homicide El �Undetermined �
W Circumstances Investigation
W Medical Certifier Name Title
0 Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 185
Burial Date Cemetery,Crematory or Facility Name
10/06/2020 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
El
and/or and/or Held
H Hold Address
N
0
O. Date Point of
toL j 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-South Glens Falls 01078
Address
136 Main St,S Glens Falls, New York 12803
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
E Address
CC
W
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/02/2020 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 10/b I Zo Place of Disposition
W (address)
W
CC°C (section) (lot number) (grave number)
L
0 Name of Sexton or Person in Charge of Premis
(ple e print)
W Signature Title (lw, rvit-
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014074
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#