Kopp, Muriel Linnea . y ( 023
NEW YORK STATE DEPARTMENT OF HEALTH )
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Muriel Linnea Kopp Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/21/2022 94 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p Manner of Death 0 Natural Cause Accident Homicide []Suicide []Undetermined ❑Pending
C.) f 'Circumstances Investigation
Ui Medical Certifier Name Title
CI Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 648
Burial Date Cemetery,Crematory or Facility Name
12/23/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0Z L. Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
d Date Point of
V)ETransportation
p by Common Shipment
Carrier Destination
[]Disinterment
Date Cemetery Address
Date Cemetery Address
[]Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
_ Remains are Shipped,If Other than Above
5. Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/23/2022 Registrar of Vital Statistics Megan.Norn(rEkctronicallySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate
Date of Disposition fZ Zy ZQ j'Place of Disposition Pt ,JN J;e,. ) Zak,e-ilz�ri.•'f' c-.1
2 (address) �1
W
N 0 (section) (lot number) (grave number)
T � Cf
el Name of Sexton or Person in Chargepf Premises > /�%/�e,/
Z (p` lease print)
ILI Signature �j ` Title OQS•2
DOH-t555(07/18)p 1 of 2 _ Y
• r
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#