Kirkwood, June .r.- ,* it /D (
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
June I. Kirkwood Female
Date of Death Age If Veteran of U.S. Armed Forces,
01 / 25 / 2018 96 War or Dates N/A
• Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Home of The Good Shepherd
til
0 Manner of Death El NaturalCause 0 Accident Homicide E Suicide ❑Undetermined 0 Pending
Circumstances Investigation
tu Medical Certifier Name Title
O James P. Gaylord MD
Address
1184 NY-50, Ballston Lake, NY 12019
Death Certificate Filed District Number �C�� Register j umber
>. J City, Town or Village Saratoga Springs 'L
<InBurial Date Cemetery or Crematory
01 / 30 / 2018 Pine View Crematory
s Entombment Address
CCremation Queensbury, NY
Date Place Removed
17 Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
iN Carrier
:: Q Disinterment Date Cemetery Address
j Q Reinterment Date Cemetery Address
I
Mi Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Nii Address
402 Maple Ave., Saratoga Sp., NY 12866
i Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IU
'` Permission is ereb granted to dispose of the human remain crib d abov as indicated.
> Date Issued i q Registrar of Vital Statistics
(signature)
District Number `I 1 Place Saratoga Springs , New York
# I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
114 Date of Disposition Y/I 1 it Place of Disposition 1+n�V.-� +�,pry
(address)
CO
Ie (section) (lot numb (grave number)
Q A
l Name of Sexton or Person in Charge of Premises i4.,itt
b ' ( lease print)
▪ Signature Title <�l<MA'i�J -
(over)
DOH-1555 (02/2004)