Kilburn, Lois Irene NEWYORK STATE DEPARTMENT OF HEALTH 1-C...... .. _Burial Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lois Irene Kilburn Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/05/2022 91 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek
p Manner of Death El Natural Cause DAccident 0 Homicide OSuicide FlUndetermined riPending
IA
Circumstances Investigation
Medical Certifier Name Title
G Kate Sauer-Jones PA
Address
112 Ski Bowl Rd,Johnsb rg Town,New York 12853
Death Certificate Filed Town Of Johnsbwg District Number Register Number
C' ,Town or Village ` 8
X Burial Date Cemetery,Crematory or Facility Name
05/11/2022 Pine View Cemetery
Entombment Address
❑Cremation Queensbury Town,New York
_Donation
0❑Removal Date Place Removed
and/or and/or Held
NHold Address
C)
aa. Date Point of
0❑Transportation Shipment
a by Common
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
F. Remains are Shipped,If Other than Above
a Address
CC
Permission Is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/06/2022 Registrar of Vital Statistics jean atComstoc.fglactron '4114
(signature)
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
W Date of Disposition 5. 1 I. DODa Place of Disposition )l L'D U.C1G D l4 ` Ladd ecns � Ivy /agOy
w moki a-a N I Be a
U) (secti (lot number) (grave number)
8 Name of Sexton or Person in Charge of Pre ' es 7.onn i 623 e dee
Z (please print)//
W Signature /� .1° .t. Title �[1 %n 7107 GyUl
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
12911
Receipt
Human remains of I - ' • delivered on , 20,
yIit,
Pine View Cemetery R presenting the funeral home named on burial,pe/rmit
Official Funeral Directors Reg.or License# t
KILBURN (LF
NAME Lois Irene Kilburn Age: 91
Lot Owner: Lois T. Kilburn
Lot# Mohican 18C Grave# 2
Case: Concrete
Died: 5/5/2 2 Interred: 5/1 1 /2 2
Funeral Home: Baker FH
Cemetery: Pine View
KILBURN ( LF)
Lot No. 18
Address RR6 Box 198 Bronk Drive, Queensbury, N.Y. 12804 Section No. C
Owner Mrs. Lois T. Kilburn Plot Mohican
- (4)44,
Date 10/10/89
Approx. 67 Superficial ft. in
Location Bounded on North by Vacant, South by Path, East by Vacant & Kelly,
West by Path.
Corner Posts
Remarks
Deed No. (and changes) 2242
Payment Record Paid in Full 10/10/89
Record of Interments
1 10 L .p
Augustus R. Kilburn 10/10/89
21thLo'‘S %. kK'% O ,s-r�y 1/- as V5 P l
3
4 4 ,( I
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5
6
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7
Form No. 01