Kurosaka, Kimiko Lynn NEW YORK STATE DEPARTMENT OF HEALTH . LF). yBurial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kimiko Lynn Kurosaka Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/08/2022 64 Years War or Dates
F— Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 13 Arbutus Drive,Queensbury Town, New York 12804
0 Manner of Death ❑X Natural Cause Accident 0Homicide ESuicide nUndetermined El Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
G Aimee Mcmaster Nurse Practitioner,Acute Care
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 145
EdBurial Date Cemetery,Crematory or Facility Name
10/13/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZZ❑Removal Date Place Removed
and/or and/or Held
F Hold Address
CO
0
O. Date Point of
V):Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment 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
H Remains are Shipped,If Other than Above
1 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/11/2022 Registrar of Vital Statistics Caroline.7fifdegarde Barber(E(ectronica/IySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition //a 113/Zp ._ /yl
2 Place of Disposition O.U IC;) C/C�- &Jory
/ (address)
W
CC CC (section) (tat number) (grave number)
I
gName of Sexton or Person in Charge of Premises J ..L I t vi 6 G,,nG,c.x•L
z (please print)
W Signature Title �''-6�'t fy OJ �°�`'�
DOH-1555(07/18)p 1 of 2
ri
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#
Town of Queensbury
Certification of Cremation
s�> Pine View Cemetery and Crematory
411.
This certifies that the remains of: Kimiko Lynn Kurosaka
were cremated on October 13 20 22 at the Pine View
(Month) (Day)
Crematorium, Queensbury, New York, and these are the cremated remains of said body.
Date of Death October 8 20 22 Age 64
(:Month) (Day)
Funeral Home Baker Funeral Home Registered No. 815
(Auth ized Signature)
KUROSAKA
NAME Klmiko Kurosaka Age: 64
Lot Owner: George Kurosaka
Lot# Algonquin 22F Grave# C
Case: Urn
Died: 1 0.1 3 .2 2 Interred: 1 0. 1 4.2 2
Funeral Home: Baker FH
Cemetery: Pine View
KUROSAKA
Owner
Mr. & Mrs. George Kurosaka
Address Plot
13 Arburus Dr. OuePnshnry, NY 12804 Algonquin
Phone # Lot #
Joan- 518-232-6893 Sec. F lot422
Deed # Date
2161 9.27.88
Cost Foundation Y - N
PD in Full 9.27.88
Location
North-Green
South-Tree
East-vacant
West-Vacant
Remarks
Record of Interments
/ 1 DOD 1 .8.97 6
George Kurosaka, Jr. 1 . 14 .97
4 2 Kimiko Kurosaka 10. 14 .22 DOD 10. 13.227
t
5 3 Jan S. Pepper 1 1 . 1 0 .01 DOD1 0. 1 _01 8
i41
4 Mikiki Kurosaka 5.26.21 DOD 5. 19_21 9
5 10
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