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Culver, Katherine Jennie i 7 sl NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Katherine Jennie Culver Female Date of Death Age If Veteran of U.S.Armed Forces, 11/06/2021 54 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital • Manner of Death WEi Ei El Undetermined Pending© Natural Cause Accident Homicide Suicide Circumstances Investigation W Medical Certifier Name Title CI Marcille Labban MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 502 ❑Burial Date Cemetery,Crematory or Facility Name 11/10/2021 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held Hold Address O a. Date Point of t!) ❑Transportation Shipment by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 5 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/09/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition //J� 0.z/Place of Disposition U'„ .3C' V eA Cr-eels 4- LU LU (address) W CC (section) ] (lot numb f r) (grave number) 0 Name of Sexton or Person in Charge o Premises i4`l I'h��r+C L�7rYx� Z _ .�(please print) W Title ('}�t1 -�'r`; Signature DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt r Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#