Collette, Elizabeth A NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Evelyn Collette Female
1.''-*.f= Date of Death Age If Veteran of U.S. Armed Forces,
July 5, 2015 93 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death
INatural Cause ElAccident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
d Medical Certifier Name Title
Michael Miles,
}_ Address
100 Park Street Glens Falls, NY 12801
• Death Certificate Filed District Number Register Number
e
City, Town or Village Glens Falls 5 b 0 r 3 L1 1
:®Burial Date Cemetery or Crematory
July 9, 2015 Pine View Cemetery
0 Entombment Address
0 Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
!: and/or Address
Hold
Date Point of
• , ❑Transportation Shipment
, by Common Destination
ist`' Carrier
Date Cemetery Address
III Disinterment
IllReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
pry; Name of Funeral Firm Making Disposition or to Whom
1.a' Remains are Shipped, If Other than Above
Address
• .- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued -7 /-7 / II--/ Registrar of Vital Statistics UJ c,i4,i
6 I (signature
District Number 56o 1 Place s21 Va \\ S NI ..)
$; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r_, Date of Disposition 07/09/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Oneida 69 & 88 2
(section) (lot number) (grave number)
Name of Se nor Person in Charge of Premises Connie L. Goedert
(please print)
Signatur ?Ki iZt- Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)