Blood, Karin NEW YORK STATE DEPARTMENT OF HEALTH
UU
Vital Records Section Burial - fransit Permit
Name First , Middle Last Sex
Harin A. Blood Female
Date of Death _7-2 01 5 Age 6 8 If Veteran of U.S. Armed Forces,
War or Dates No
hr Place of Death Tnof Moreau Hospita, Institution or 4 Woodland Drive
W City, Town or Village Street Address
a Manner of Death❑x Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ri❑Pending
Ltf Circumstances Investigation
at Medical Certifier Name Title
C John Stoutenburg MD
Address
Park St. South Glens Falls, New York
Death Certificate Filed Tnof Moreau District Number Register Number
City, Town or Village y$
❑Burial Date Cemetery or Crematory
Aug. 10, 2015 Pineview Crematory
❑Entombment Address
['Cremation Quaker Road Queensbury, New York 12804
Date Place Removed
• Removal and/or Held
C and/or Address
H Hold
U) _
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home
01 078
Address 136 Main St. South Glens Falls, New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
1Z
t:LI
P' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Aug• 10, , liegistrar of Vital Statistics k/C1 4✓4/il- 44 ( /--_
(signature)
District NumberPlace Tn. o f Moreau, New York
q S(o N
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition $/IiJ 16 Place of Disposition l'4e LL c..c...16( .-.
(address)
w
CA
CC (section) /A (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises t 4riod JF. '4
jZ (please print)
iii Signature [C Title (// Opet
(over)
•
DOH-1555 (02/2004)