Coolen, Barbara NEW YORK STATE DEPARTMENT OF HEALTH #6SI.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Barbara Frances Coolen Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 7, 2012 82 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
$ Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 1-1 Undetermined ❑ Pending
0 Circumstances Investigation
W Medical Certifier Name Title
0 Daniel C. Larson, M.D. Dr.
Address
Broad Street Glen Falls, NY 12801
Death Certificate Filed Distric Numb r RegisterNumber
City, Town or Village Glens Falls JJ �5
❑Burial Date Cemetery or Crematory
December 11, 2012 Pine View Crematory
❑Entombment Address
®Cremation
Date Place Removed
El and/or
and/or Held
and/or Address
E Hold
to Date Point of
0. ❑Transportation Shipment
• by Common Destination
O Carrier
Date Cemetery Address
III Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
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
a Address
16
ii" Permission is hereby granted to dispose of the human remains descr e. a. .v irj fed,
2- Registrar of Vital Statistics
Date Issued /�//0��� g '
AZ
(signature)
District Number 3'0/ Place '7e0 / # ,1 , 4>4
I certify that the remains of the decedent identified above were disposed off in)accordance with this permit on:
w Date of Disposition 12/11/2012 Place of Disposition '�,,,A.LJ C+iwwtor04.
(address)
W'
0
I r (section) / (Lt number) ., (grave number)
0 Name of Sexton or Person in Charg of Premises "AreJ �— Sant
z ( ease print)
W Signature Ld__ Title GPcw► L
T
(over)
DOH-1555 (02/2004)