Kmetz, Louise NEW YORK STATE DEPARTMENT OF HEALTH y�
Vital Records Section Burial - Transit Permit
0. Name First Middle Last Sex
Louise Ellen Kmetz Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/10/2018 71 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
'ry Manner of Death � Undetermined Pending
Natural Cause Accident Homicide Suicide
Circunstances Investigation
Medical Certifier Name Title
Sean Bain MD
fN Address
100 Park St,Glens Falls,New York 12801
WI Death Certificate Filed District Number Rec,'ster Number
City, Town or Village Glens Falls 5601 587
Lite W. ❑Burial Date Cemetery or Crematory
12/13/2018 Pine View Crematory
0 Entombment Address
®Cremation Queensbury Town, New York
ifill
AO Date Place Removed
;❑Removal
and/or Held
- , and/or Address
Hold
Date Point of
Q Transportation Shipment
:': by Common Destination
if Carrier
-. Date Cemetery Address
Disinterment
_ Date Cemetery Address
Reinterment
Permit Issued to Registration Number
ill Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
it 11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Pe
Remains are Shipped, If Other than Above
PAS Address
7,11
Permission is hereby granted to dispose of the human remains described above as indicated.
il
Date Issued 12/13/2018 Registrar of Vital Statistics 106ertA Curtis(Efctronica1 y Signed)
Pt (signature)
VI District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 121,111% Place of Disposition gmL, (,rho.io,r
,s" (address)
f
(section) I (lot number) (grave number)
' 1 Name of Sexton or Person in Charge of emises /411,;(4.1.p: JeAOtt
(pi se print)
Signature W't Title ntEttA AL
(over)
DOH-1555 (02/2004)