Collins, John it , t
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Collins Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 16, 2017 59 War or Dates
• Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 10 B Manor Drive
Manner of Death X Natural Cause ❑Accident n Homicide Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Paul Bachman
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Registe umber
0 City, Town or Village Queensbury 5657 d
❑Burial Date Cemetery or Crematory
February 17, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z
❑Removal and/or Held
o and/or Address
Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
—
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804 0%' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
)f,
' , Permission is hereby granted to dispose of the human r m ins described ab ve as indicated.
i Date Issued c3-/ I-7 LRegistrar of Vital Statistics -- ���-`� �
' (signature)
wii
f,,, District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Z 1/7 Place of Disposition P, ' v; 'uJ 6:/. n i„je
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W
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0 (section) i (lot number) (grave number)
ZZ Name of Sexton or er�son in Charge of Premises ire:.vl ( r' G A-G.-
(please print)
ILISignature /`,,vi,..�" � Title c.te2 }c,/y
Gf (over)
DOH-1555(02/2004)