Caunter, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section J
Gws
Name First Middle Last Sex
yy Kathleen J. Caunter Female
Date of Death Age If Veteran of U.S. Armed Forces,
-a, July 4,2014 58 War or Dates
4= Place of Death Hospital, Institution or
• City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
tt# Circumstances Investigation
tti Ca Medical Certifier Name Title
re Gary Scidmore
Address
6930 State Rt.8,Brant Lake,NY 12815
• Death Certificate Filed District Number Register Number
• City, Town or Village Glens Falls 5601 3 L g
El Burial Date Cemetery or Crematory
July 7,2014 Pine View Crematory
❑Entombment Address
1-3 Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
Hold
N
p Date Point of
y 1 I Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
(Reinterment Date Cemetery Address
Permit Issued to Registration Number
:: ., Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
o Address
a•
:;:: Permission is hereby granteddispose to dis ose of the human remains described above as indicated.
Date Issued -. t -7 I I t( Registrar of Vital Statistics l./ )
r� ���� (signature)
nr
_5 District Number 5601 Place Glens Falls/ W F ry
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I--
ui Date of Disposition 7- 0114 Place of Disposition ,_ t5-- Ci- for --
2 (address)
W
CO
CC (section) dstii,
{lot numbe � (grave number)
0p Name of Sexton or Person i Charge of Premises th
(please print)
W Signature .! ,�� Title _ �' ✓hq'(�
(over)
DOH-1555 (02/2004)