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Elrick, Kathy It ,Cy? NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Kathy Lynn Elrick Female Date of Death Age If Veteran of U.S. Armed Forces, 07/13/2017 53 Years War or Dates t Place of Death Hospital, Institution or Eti City, Town or Village Glens Falls Street Address Glens Falls Hospital 1 Manner of Death©Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined FlPending Circumstances Investigation '§ Medical Certifier Name Title Darci Gaiotti-Grubbs MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number , City, Town or Village Glens Falls 5601 386 N❑Burial ' Date Cemetery or Crematory 07/17/2017 Pine View Crematorium ❑Entombment Address ,_®Cremation Queensbury Town, New York Date Place Removed Removal and/or Held ,riAa❑and/or Address Hold O Date Point of CL Q Transportation Shipment G by Common Destination Carrier Q Disinterment Date Cemetery Address 7 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 1,:.>; Address 68 Main Stpo Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address 'U 4' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/17/2017 Registrar of Vital Statistics ,6ertACurtis ElectronicaaySigned (signature) District Number 5601 Place Glens Falls, New York SI certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 1i tg,O Place of Disposition "fti+4 / l'.••..-at7Nrl..., (address) w Ix (section) A (lot number) (grave number) Name of Sexton or Person in Charge of Prem' es [4f.s 3twari ,zr (pl se print) Signature 4 Title f�Emit (over) DOH-1555 (02/2004)