Collins, Emmett NEW YORK STATE DEPARTMENT OF HEALTH 4 1 3
Vital Records Section Burial - Transit Permit
'; Name First Middle Last Sex
A ova Emmett Michael Matthew Collins male
€3 Date of Death Age If Veteran of U.S. Armed Forces,
December 30, 2017 .,-r War or Dates
. Place of Death Hospital, Institution or
r " City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
W' Medical Certifier Name Title
0 Jennifer Bashant MD,
Address
102 Park St. Glens F: s, NY 12801
Death Certificate Filed ' pieta Number Register Number
'' Ci , Town or Village 5601 �j
-.❑Burial Date Cemetery or Crematory
January 2, 2018 Pine View Crematorium
❑Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
4 Date Point of
d ❑Transportation Shipment
by Common Destination
0 Carrier
,:' El Disinterment Date Cemetery Address
I
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc. 00281
Address
'. Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
, Remains are Shipped, If Other than Above
Address
" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1Z (`� Registrar of Vital Statistics Ia;\; `,A.)J\,N cr
i (signature)
District Number 5601 Place G \QA, c in,V. t J y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Li Date of Disposition 01/02/2018 Place of Disposition Quaker Road Queensbury,NY 12804
p p rY,
(address)
.10
i (section) ifi (lot number) (grave number)
zName of Sexton or Person in Charge of remises - J .�...4,ii'
"lease print)
Signature �� Title Tt
(over)
DOH-1555 (02/2004)