Koerner, Grace 1`
` = * 71?
NEW YORK STATE DEPARTMENT OF HEALTH _
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
• - Grace Koerner Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/22/2017 83 Years War or Dates
Place of Death Hospital, Institution or
'` City, Town or Village Saratoga springs Street Address Saratoga Hospital
Manner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending
`ti Circumstances Investigation
Medical Certifier Name Title
mi Derek Smith MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 , 468
0 Burial Date Cemetery or Crematory
et„:, 09/25/2017 Pine View Crematory
, ❑Entombment Address
s
®
,r Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
`f'Q Disinterment Date Cemetery Address
A?
Vie:
Date CemeteryAddress
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
T Address
,,t
Permission is hereby granted to dispose of the human remains described above as indicated.
-` Date Issued 09/25/2017 Registrar of Vital Statistics John T<Franck B(ectronicaaySigned
. x (signature)
zN
ei District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
_ Date of Disposition 'lit(n Place of Disposition P.,4/N. 6,.,.s7t01".
(address)
rt-
rz
(section) ///�lot number) C (grave number)
iv
'0, Name of Sexton or Person in Charge of Pre ises to my- ,1,tt
(p/ se print)
e• : Signature L 1 .N TitleAmor.-c
(over)
DOH-1555 (02/2004)