Knurek, Barbara NEW YORK STATE DEPARTMENT OF HEALTH { ` • ' # _(WZ-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Barbara Janice Knurek Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 11, 2017 86 War or Dates
Place of Death Hospital, Institution or
it City, Town or Village Fort Edward Street Address 1082 Burgoyne Ave
U Manner of Death li Natural Cause Accident El Homicide 0 Suicide ❑ Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0, James North, M.D
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed District ATp Reel Number
City, Town or Village G1
❑Burial Date Cemetery or Crematory
June 14, 2017 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
` Removal and/or Held
t and/or Address
,. Hold
CO Date Point of
0 0 Transportation Shipment
CO by Common Destination
15 Carrier
Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
ki
t: Permit Issued to Registration Number
k. Name of Funeral Home Carleton Funeral Home, Inc. 00281
, Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
H_ Remains are Shipped, If Other than Above _
2 Address
CZ •
W
Permission is h reby ranted to dispose of the human re ins describ d a ve as ' dicated. .
Date Issued /0 /IA 1 Registrar of Vital Statistics
(signatu )
District Numberrf 55 Place 1 GI/Olt - � (duJ ct&ci
r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 06/14/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
(0,
(section) (lot number) r, (grave number)
cr Name of Sexton or Person in Charge o Premises (An Lr .JL"nt(l}
W6 4 (pie se print)
Signature a1 Title mik ._
(over)
DOH-1555 (02/2004)