Kim, Eileen NEW YORK STATE DEPARTMENT OF HEALTH 4 ICL
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eileen Mary Kim Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 18, 2017 64 War or Dates
o.
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 11 Hickory Hollow Road
z Manner of Death ❑Natural Cause Accident n Homicide ❑Suicide n Undetermined Pending
Circumstances Investigation
• Medical Certillec N Title
Addr
•
c."ccA - "c.� T\c'61 ` i 4
• Death Certificate Filedistrict Number R is Q �er Number
City, Town or Village Queensbury,NY 5657 p
❑Burial Date Cemetery or Crematory
❑Entombment February 24, 2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Zn Removal and/or Held
o: and/or Address
Hold
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0 Date Point of
0 ❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
} Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rgrrins described ab v as indicated.
Date Issued ( �( 1 (� Statistics egistrar of Vital c� a-/1��`
;,,,,
(signature)
„j District Number
ff j "Th Place d EsCr-Ns) 1 ,-..
41.
I certify that the remains of the decedent identified above were disposed of in acco ance wit this permit on:
p I Place of Disposition lip.,,
W Date of Disposition Z 2��11 p ae ew+a +tr--
2 (address)
LU
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ci1Z (section) ,/ (lot numbers (grave number)
Name of Sexton or Person in Charge of Premises (4rS Aar
Z please print)
W Signature a ,jam, Title ref Mi .
C� (over)
DOH-1555(02/2004)