Kimball, Carol NEW YORK STATE DEPARTMENT OF HEALTH s 'I Burial - Transitermit
Vital Records Section
Name First Middle Last Sex
Carol J. Kimball Female
Date of Death Age If Veteran of U.S.Armed Forces,
i January 1, 2011 10 War or Dates
Z Place of Death Hospital, Institution or
W City,Town, or Village Whitehall Street Address Residence
G Manner of Death ❑x Natural Cause ❑ Accident ❑Homicide ElSuicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Michael Lynch, M.D. Dr.
0 Address
160 Allen Street, Rutland, VT 05701
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall
❑Burial Date Cemetery or Crematory
January 5, 2011 Pineview Crematory
❑Entombment Address
Z ®Cremation Queensbury, New York
Date Place Removed
0 ❑Removal and/or Held
and/or Address
I' Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
0Carrier
Date Cemetery Address
5 ❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
F= Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
0.
Permission is hereby granted to dispose of the human remains described - 'ove as indicated.
Date Issued /- 7 0W/ Registrar of Vital Statistics ,r &.
•t gnature)
District Number .5:76 C, Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition Place of Disposition _
W (address)
0
It
0 (section) (lot number) (grave number)
0
Z• Name of Sexton or Person in Charge of Premises
W (please print)
Signature Title
(over)
DOH-1555 (02/2004)