Coons, Sandra NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sandra Coons Female
Date of Death Age If Veteran of U.S. Armed Forces,
p 09/12/2017 80 Years War or Dates
w Place of Death Hospital, Institution or
City, Town or Village Johnstown Street Address Wells Nursing Home Inc
Manner of Death 0 Natural Cause 0 Accident 0 Homicide E Suicide Undetermined El Pending
Circumstances Investigation
CI
14 Medical Certifier Name Title
John Glenn MD
Address
201 W Madison Ave,Johnstown,New York 12095
Death Certificate Filed District Number Register Number
i
City, Town or Village Johnstown 1702 134
i ❑Burial Date Cemetery or Crematory
v 09/14/2017 Pine View Crematory
❑Entombment Address
®Cremation QueensburyTown, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
• Date Point of
i 0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
r Q Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
, 402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
n' Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/13/2017 Registrar of Vital Statistics catfiyAnnevanaatyne ECectronicalrysigned-
(signature)
91,
District Number 1702 Place Johnstown, New York
%y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,1 Date of Disposition Iissirn Place of Disposition Qntii-, twb.Qto rs•—%.,
(address)
4
(section) (lot aumber) (grave number)
Name of Sexton or Person in Charge of P emises 4.,.1.0.e."
5iniO'
(plea le print)
Signature IA Title i KPh('Vit
(over)
DOH-1555 (02/2004)