Boothby, Karen # tigfNEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Karen Boothby Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/11/2022 74 Years War or Dates
E._ Place of Death Hospital,Institution or
W City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
p Manner of Death n Natural Cause Accident n Homicide Suicide nUndetermined []Pending
W 1 ' I I I
V Circumstances Investigation
QMedical Certifier Name Title
Brandii Baker NP
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed Town Of Argyle District Number Register Number
City,Town or Village 5750 35
Burial Date Cemetery,Crematory or Facility Name
06/14/2022 Pine View Crematory
nEntombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
F and/or and/or Held
to Hold Address
0
a Date Point of
co❑Transportation
p by Common Shipment
Carrier Destination
ElDisinterment 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
-- Remains are Shipped,If Other than Above
M Address
CC
W
0., Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/13/2022 Registrar of Vital Statistics Shelley 914ckernon(E(ectronical(ySigned)
(signature)
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
W Date of Disposition (p TM_ Place of Disposition _ ZIL, 641�-
2 (address)
W
CO
O (section) (lot number) (grave number)
13 Name of Sexton or Person in Charge of Premi es a'
W `/ Al;I(please print)
Signature "' Title �( +N i��
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
1
1 Human remains of delivered on , 20
I
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#