Forkin, Louise Henrietta r. @ . 30
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Louise Henrietta Forkin Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/07/2022 80 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death I INaturalCause nAccident Homicide Suicide Undetermined ❑Pending
InI ' Circumstances Investigation
W Medical Certifier Name Title
0 Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 34
IIIBurial Date Cemetery,Crematory or Facility Name
04/08/2022 Pine View Crematory
nEntombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
CL Date Point of
toTransportation Shipment
p by Common
Carrier Destination
nDisinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
f- Remains are Shipped,If Other than Above
5 Address
ir
W
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/08/2022 Registrar of Vital Statistics Aimee L Mahoney(E(ectronicaCCySigned)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ (� R4 Z Date of Dispositiong-�o2� Place of Disposition ,�� �j��
W W (address)
CC (section �'/ot num er) (grave number)
0 Name of Sexton or Person in Char of Premi sue' � >�
Z (please print)
Ill / "V Signature Title 40e i6�
g
DOH-1555(07/18)p 1 of 2
-t
' Public Health Law Sec. 4145(2b)
4
Receipt
•
Human remains of delivered on , 20
•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#