Kimball, Laurel t i , # 2.
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
3''I Name " First Middle Last Sex
Laurel Joan Kimball Female
Date of Death Age If Veteran of U.S. Armed Forces,
g 03/22/2018 74 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause Ei Accident Homicide 0 Suicide ❑ Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Farhana Kamal MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 149
❑Burial Date Cemetery or Crematory
03/26/2018 Pine View Crematory
❑Entombment Address
igaremaQueensbury Town, New York
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
b Date Cemetery Address❑Disinterment
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
..ti Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
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 03/23/2018 Registrar of Vital Statistics co6ertA Curtis(Etectronica(Cy Signed)
(signature)
District Number 5601 Place Glens Falls, New York
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3iegiiy Place of Disposition
(address)
I
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ,
(please print)
l W /�"T/
Signature Title (Rvohick,
(over)
DOH-1555 (02/2004)