Sommer, Karen Leigh 3gc
RK STATE DEPARTMENT OF HEALTH OLF
NEW YO Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Karen Leigh Sommer Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/02/2022 75 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death E1 Natural Cause Accident Ell Homicide Suicide FlUndetermined ]Pending
W Circumstances ' 'Investigation
V Title
W Medical Certifier Name
C Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 247
Burial Date Cemetery,Crematory or Facility Name
05/06/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Date Place Removed
❑Removal and/or Held
Hand/or
Hold Address
0
Date Point of
U3❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
0 Reinterment
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
i- Remains are Shipped,If Other than Above
2 Address
Q
W --
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/05/2022 Registrar of Vital Statistics Megan NoCin(ECectronica1Ty Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate of Disposition 5 I to I ZZ. Place of Disposition .l i,e/�._. �—
2 S1
W
Cl) (section) (lot number) (grave number)
G Name of Sexton or Person in Charge of Premises g
(please print)
Z . �� 6('-'f�'*47t?IC.
W I
Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on _ , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# h"