Boucher, Kathryn NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ` IN Burial - Transit Permit
at Name First Middle Last Sex
Kathryn Ann Boucher Female
•
. Date of Death Age If Veteran of U.S. Armed Forces,
October 29, 2013 94 War or Dates
Place of Death Hospital, Institution or
% City, Town or Village Glens Falls Street Address Glens Falls Hospital
r+ Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ri❑ Pending
4 Circumstances Investigation
Medical Certifier Name Title
Thomas Kandora, M.D. Dr.
• Address
Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Jr r Register Number
`' City, Town or Village Glens Falls I-1 t-/ 6
❑Burial Date Cemetery or Crematory
October 30, 2013 Pine View Crematory
7❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
•
Date Place Removed
❑ Removal and/or Held
ig and/or Address
Hold
Date Point of
;❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
41
Permit Issued to Registration Number
IA-
•
Name of Funeral Home M. B. Kilmer Funeral Home 01079
FN= Address
1 ' 82 Broadway, Fort Edward NY 12828
s Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t O / 3 i //.3 Registrar of Vital Statistics 1,0 C),A4y.,Q
-,m
(signature)
District Number.Gp / Place 6 S T A 1 ( s Ili T
/
it I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/30/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) �� � (lot dumber) (grave number)
Name of Sexton o 'Pers n in e of Premisesri- a`�`� d
f n (please print) L
Signature Title `! �'¢/-'�' ST "
(over)
DOH-1555 (02/2004)