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Kim, Hyung Rin
...----,„\ NEW YORK STATE DEPARTMENT OF HEALTH (LF Bureau of Vital Records --- Burial - Transit Permit Name First Middle Last Sex Hyung Rin Kim Male Date of Death Age If Veteran of U.S.Armed Forces, 12/04/2021 94 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Queensbury Town Street Address 23 Fitzgerald Road,Queensbury Town,New York 12804 p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation 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 233 0 Burial Date Cemetery,Crematory or Facility Name 12/09/2021 Pine View Cemetery ❑Entombment Address ❑Cremation Queensbury,New York ElDonation ZRemoval Date Place Removed and/or and/or Held H Hold Address N 0 Q. 1-1 Date Point of u) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped,If Other than Above IAddress W 0` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/07/2021 Registrar of Vital Statistics CarolineJfi&1egarde Barber(ECectronica1Cy Signed) (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: Date of Disposition 12.9 .21 Place of Disposition 21 Quaker Rd. Queensbury 12804 UJ 2 (address) W Ondawa Ext. 13 1 C (section) (lot number) (grave number) SName of Sexton o erson in Charge of Premises Connie Goedert Z ` n .,/ (please print) W Signatures—? I- fI CX , Title Superintendent (.I DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012885 Receipt Gi Human remains of + , a delivered on_ , 20: i /Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# KIM NAME Hyung Rin Kim / Age: 94 Lot Owner: Hyung R & Eleanora Kim Lot# Ondawa Ext 13 Grave# Case: Concrete Died: 1 2/4/21 Interred: 1 2.9.21 Funeral Home: Singleton Sullivan Potter Cemetery: Pine View