Collin, Debbie C ry
NEW YORK STATE DEPARTMENT OF HEALTH '" 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Debbie K Collin Female
,,' Date of Death Age If Veteran of U.S. Armed Forces,
<;�� January 28, 2017 64 War or Dates
f�f
'"X.X. Place of Death Hospital, Institution or
City, Town or Village ueensbu Street Address 16 Fox Farm Road
Manner of Death X Natural Cause n Accident ❑Homicide n Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Reeves Dr.
94
Address
3 Irongate Center,Glens Falls,NY 12801
:;`F Death Certificate Filed District Number a.;<. City, Town or Village Register Number
.:.:.<: : 9 Queensbury 5657
❑Burial Date Cemetery or Crematory
January 30, 2017 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
Ds ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
{s Permit Issued to Registration Number
f`' Name of Funeral Home Regan Dennytafford Funeral Home 01443
r: g Y
`; Address
%; 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
'x: Remains are Shipped, If Other than Above
IAddress
Permission is hereby granted to dispose of the human remains described above as indicated.
ii , � E C
':: Date Issued I i1 Registrar of Vital Statistics rZ.tti
..„„
f .�% (signature)
Mg
in District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LuDate of Disposition 2I I I 7 Place of Disposition EntVaddressc w,tal�
W
U)
0 (section) (lot number) c (grave number)
pName of Sexton or Person in Charge of Pr mises �4r; -F J1iiitr
Z ( lease print)
W p
Signature C r" Title t ,I i it
(over)
DOH-1555(02/2004)