LaRock, Katherine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last
Katherine Sex
F. LaRock Date of Death Age If Veteran of U.S. Armed Forces, Female
Ma 18 19 9 9 74 War or Dates
Place of Death Hospital, Institution or
City, Town or Villag Glens Falls Street Addres§lens Falls Hospital
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Medical Certifier Name Circumstances Investigation
Title
Surendra K. Nevadia Dr.
Address
92 Broad Street, Glens Falls, NY 12801
Death Certificate Filed District Number
City, Town or Village Glens Falls 5601
Register Number
Date Cemetery or 2
❑Burial Ma 20 1999 Crematory
Pine View Cremator
Address
Cremation Quaker Road
Date 4ueensbury, NY 12RQ4
Z❑Removal Place Removed
and/or and/or Held
Hold Address
55 Transportation Date Point of
a`Q
Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
[j Reinterment Date Cemetery Address
Permit Issued to
Name of Funeral Home M. B. Kilmer Funeral Home Registration Number
Address 01058
136 Main Street, South Glens Falls, NY 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 5 )2c G 9 Registrar of Vital Statistics U^j
(signature)
District Number 56 O I Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
Date of Disposition Place Place of Disposition
W (address)
M ( ection) (lot numb (grave number)
ly
Name of Sexton or Person in Charge of Premises '.a,FJ �zTA
�
(please print)
Signature ,�if� J`' Title C- 1W �! f
DOH-1555 (10/89) p. 1 of 2 VS-61