Crocker, Claudette NEW YORK STATE DEPARTMENT OF HEALTHY ° 'l / 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Claudette Crocker Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 16, 2011 -1-7 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
-
Manner of Death ElNatural Cause Accident Homicide 0 Suicide 0 Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
John P. Stoutenburg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed Dis der i umber
City, Town or Village n?a 4
a❑Burial Date Cemetery orCrematory
February 17, 2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
-. and/or
Hold Address
Date Point of
a Li Transportation Shipment
Ott by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01097
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
remains described b ve as indicated.
Permission is hereby tgranted to dispose of the human ema� sabove
Date Issued 21 17/ f) Registrar of Vital Statistics 1Wcx& X )
(sign ure)
District Number 5-60 I Place b L.n..S \\s (\ I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/17/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
& :: (section) (lot nu ) (grave number)
Name of Sexton or Pe n in Char of Premises (irruf'Jer r -
(please print)
g til --Si nature Title City=rvi►TC
(over)
DOH-1555 (02/2004)