Kopf, Karen NEW YORK STATE DEPARTMENT OF HEALTH .:
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Karen Louise Kopf Female
Date of Death Age If Veteran of U.S. Armed Forces,
4- 08/30/2018 69 Years War or Dates
Place of Death Hospital, Institution or
iiii City, Town or Village Albany Street Address Albany Medical Center Hospital
X Manner of Death X Natural Cause Accident 1 Homicide Suicide Undetermined Pending
Circumstances Investigation
ral Medical Certifier Name Title
rii Christopher Li MD
-1-1.,, 43 New Scotland Ave,Albany,New York 12208
rz,_ District Number Register Number
.4.4_Burial Date Cemetery or Crematory
R ' 4 _
Entombment
Cremation
- Date Place Removed
r-1 Removal
rii'. and/or Held
Ir' '
U, Date Point of
Transportation Shipment
, ...:, by Common Destination
;7"-ii: Carrier
D_ Cemetery Address
317., Disinterment
Date Cemetery Address
.-A-- Reinterment
-A Permit Issued to
-,-:',; Name of Funeral Home M B Kilmer Funeral Horne-South Glens Falls
till Address Registration Number
01078
York 12803
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 09/04/2018 Registrar of Vital Statistics rDanielleS Gillespie(Electronically Signed)
(signature)
District Number owlPlace Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Mi Date of Disposition it+((t f Place of Disposition eiV., (
(address)
Hi
-84 (section) (lot nu ber) (grave number)
1-4
Name of Sexton or Person in Charge of Premises ' k
/�� (please priht)
S �
Signature Lrf' ,L Title (WO0
(over)
DOH-1555(02/2004)