WilderLocke- Kimberly 1C
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kimberly LockeXilder, Female
Doe of Beath Age If Veteran of U.S.Armed Forces,
06/04/2022 55 Years War or Dates
Place of Death Hospital,Institution or
z City,Town or Village Hudson Street Address Columbia Memorial Hospital
UJ Manner of Death Undetermined Pending
W Natural Cause Accident Ei Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
G Laurence Harris MD
Address
71 Prospect Ave,Hudson,New York 12534
Death Certificate Filed City Of Hudson District Number Register Number
City,Town or Village 1001 123
Burial Date Cemetery,Crematory or Facility Name
06/06/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
U) Transportation
ES Common Shipment
Carrier • Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
Address
6357 Nys Rte#30, Indian Lake,New York 12842
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
a Address
ft
W
a.. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/06/2022 Registrar of Vital Statistics Tracy Sue Delaney(Electronically Signed)
(signature/
District Number 1001 Place City Of Hudson
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition b 13 I it Place of Disposition
(address)
W
Cr
U) (section) fi (lot number) (grave number)
gName of Sexton or Person in Charge of Premises "r`n' n1
Z (p/ese print)
W Signature Title CICM4
D0 H-1555(07/18)p 1 of 2
? 'mac
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#