LaBombard, Katharine T \ 615
NEW YORK STATE DEPARTMENT OF HEALTH LF} Burial - Transit Permi
Bureau of Vital Records
Name First Middle Last Sex
Katharine T.LaBombard Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/28/2022 65 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
`p Manner of Death ❑X Natural Cause Accident El Homicide Suicide Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Eric Santell NP
Address
112 Ski Bowl Rd,Johnsburg Town, New York 12853
Death Certificate Filed Town Of Johnsburg District Number Register Number
City,Town or Village 5655 31
Burial Date Cemetery,Crematory or Facility Name
11/30/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
- and/or and/or Held
- Hold Address
0
a Date Point of
U) Transportation
ES Common Shipment
Carrier Destination
o
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
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
Remains are Shipped,If Other than Above
5* Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/29/2022 Registrar of Vital Statistics lean 11 Comstock(E(ectronica(CySigned)
(signature)
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1100 IlL Place of Disposition I '•'�u
2 (address)
W
CC
CC (section) (lot number) (grave number)
SName of Sexton or Person in a of Premises
Z (p ase print)
W Signature Title aZION
DOH-1555(07/18)p 1 of 2
�.. r V / £.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Repre enting the funeral home named on burial permit
Official Funeral Directors Reg.or License# !`