Karkoski, Katherine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mid. :- Last Sex
Katherine Mina Karkoski Female
Date of Death Age .S. Armed Forces,
- 11/21/2018 78 Years . . •ates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Ili Medical Certifier Name Title
Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 551
El Burial Date Cemetery or Crematory
11/29/2018 Pine View Crematory
ID Entombment Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox&Regan 01821
Address
11 Algonkin St,Ticonderoga,New York 12883
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 11/23/2018 Registrar of Vital Statistics 12p6ertA Curtis(ECectronicalTySigned)
(signature)
District Number 5601 Place Glens Falls, New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1 `'a`�--1V Place of Disposition �h� vD e,w Qdr-kryori Eofy
(address)
fit
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises kf MLy S�ja,t c,S
(please print)
CirtAicactc
SignatureM,c Title
(over)
DOH-1555 (02/2004)