Kurosaka , Mikiko LF
Town of Queensbury
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of: Mikiko Kurosaka
were cremated on May , 25 20 21 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death May 19 20 21 Age 90
(Month) (Day)
Funeral Home Baker Registered No. 445
(A horized Signature)
, L�1j•
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mikiko Kurosaka Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/19/2021 90 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 13 Arbutus Drive, Queensbury Town, New York 12804
Manner of Death ❑X Natural Cause 0 Accident Homicide ❑Suicide Undetermined Pending
UCircumstances Investigation
WD Medical Certifier Name Title
Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 110
Burial Date Cemetery,Crematory or Facility Name
05/25/2021 Pine View Crematory
❑Entombment Address
aCremation Queensbury Town,New York
Donation
OZ ❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
Date Point of
(d ❑Transportation
CI by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
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
1— Remains are Shipped,If Other than Above
5 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/21/2021 Registrar of Vital Statistics CaroIsnexkfegarde Bar6er(Eketromi- 5 5gned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
Z Date of Disposition -2�j:�'i,� IL/Place of Disposition )Jb4 J�7i,.cr� 'Z ertw`
lL Z'
2 (addre sl
W
Cl) (section) (lot number) (grave number)
0 Name of Sexton or Perso in Charge of Premises At,1 r I�,n (Ja✓r°ectt:
Z (please print)
IL Signature / ,L'/ Title �n� �" d
DOH-1555(07/18)p 1 of
Public Health Law Sec. 4145(2b) _ , 1 it 1 3
Receipt
Human remains of f, delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
KUROSAKA (LFNAME Mikiko Kurosaka Age: 90
Lot Owner:Mr & Mrs George Kurosaka
Lot# Algonquin 22 F Grave# 3 C
Case: Urn
Died: 5/1 9/2 0 21 Interred: 5/2 6/2 0 21
Funeral Home: Baker FH
Cemetery: Pine View
KUROSAKA
Owner
Mr. & Mrs. George Kurosaka
Address Plot
13 Arburus Dr. Queen.hury, NY 12804 A7gnngnin
Phone # Lot #
Joan- 518-232-6893 Sec. F lot#22
Deed # Date
2161 9.27.88
Cost Foundation Y - N
PD in Full 9.27.88
Location
North-Green
South-Tree
East-vacant
West-Vacant
Remarks
Record of Interments
4 1 DOD 1 .8.97 6
George Kurosaka, Jr. 1 . 14.97
4 2 Kimiko Kurosaka 10 .14.22 DOD 10. 13.227
5 3 Jan S. Pepper 11 .10.01 DOD10.1 .01 8
4 Mikiki Kurosaka 5.26.21 DOD 5. 19_71 9
5 10
f