Kibling, Nathalie NEW YORK STATE DEPARTMENT OF HEALTH fr 1 U5
Vital Records Section Burial - Transit Permit
'
Name First Middle Last Sex
Nathalie Ann Kibling Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 22, 2012 61 War or Dates
i"- Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death .] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Marvin Davidowitz, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Wiper R ,Jumber
City, Town or Village ' O(
❑Burial Date Cemetery or Crematory
February 23, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
p Hold St. Paul's Cemetery
0 Date Point of
eL 0 Transportation Shipment
0
_ by Common Destination
O Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
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
I— Remains are Shipped, If Other than Above
M Address
LE
tit
il- Permission is hereby granted to dispose of the human remains s rib d a ve icated.
Date Issued Q ` ZEJ/2.- Registrar of Vital Statistics � r/
(signature)
District Number ST c7/ Place �/G:,o, , _7%i /7
FI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition Place of Disposition
2 (address)
W;
...........
re
(section) (lot number) (grave number)
CI• Name of Sexton or Person in Charge of Premises
-Z,. (please print)
W`: Signature Title
(over)
DOH-1555 (02/2004)