Krulls, Jacqueline S NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Jacqueline S.Krulls Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/17/2022 90 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Lake George Town Street Address 11 Carriage Hill Road,Lake George Town,New York 12845
111.1
p Manner of Death ❑X Natural Cause Accident Homicide OSuicide Undetermined El Pending
0 Circumstances Investigation
W Medical Certifier Name Title
0 Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Lake George District Number Register Number
City,Town or Village 5651 15
Burial Date Cemetery,Crematory or Facility Name
07/20/2022 Pine View Crematory
Entombment Address
aCremation Queensbury Town,New York
Donation
ElRemoval Date Place Removed
and/or and/or Held
H Hold Address
O
d Date Point of
fA Transportation
15by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F+ Remains are Shipped,If Other than Above
2 Address
LLJ
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/20/2022 Registrar of Vital Statistics Patricia cR fMCKjnney Schuster(ECectronica1TySigned)
(signature)
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition I-it� t Place of Disposition
2 (address)
W
(section) (lot number)C\, 'M (grave number/
8 Name of Sexton or Person in Charge of Premises �-- �M+K�'
Z (pp ase print)
W Signature a Title 174,Wkl vZ.
DOH-1555(07/18)p 1 of 2
1 0 7 ('' 0 F: 4
Public Health Law Sec. 4145(2b)
Receipt
1
1
Human remains of ,. ` " delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# `