Collins, Francis Ci ?
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Francis T.Collins Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/03/2017 84 Years War or Dates
Place of Death Hospital, Institution or
v` City, Town or Village Glens Falls Street Address Glens Falls Hospital
' ' Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Jennifer Donovan DO
Address
100 Park St,Glens Falls,New York 12801
tea°
Death Certificate Filed District Number Register Number
>' City, Town or Village Glens Falls 5601 363
❑Burial Date Cemetery or Crematory
07/10/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
>' < Removal and/or Held
. and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
❑Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
-:. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/06/2017 Registrar of Vital Statistics tig6ertACurtis ECectronicallySigned
(signature)
District Number 5601 Place Glens Falls, New York
»�t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I Date of Disposition 71 riln Place of Disposition fruu✓ �i+++„�l�-•
(address)
10,
cal (section) (lot number) ,¢ (grave number)
0 Name of Sexton or Person in Charge of Premises / S i"1
(pl se print)
Signature Title ar'"rliI"i�
(over)
DOH-1555 (02/2004)