Collins, Shirley NEW YORK ETATE'DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:: Name First Middle Last Sex
1 Shirley I. Collins Female
M Date of Death Age If Veteran of U.S. Armed Forces,
]:!i February 13, 2014 77 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 8 Kelly Avenue
Manner of Death Natural Cause I I Accident I J Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gif Address
Death Certificate Filed District Number Register Number
r:''r City, Town or Village Hudson Falls 5 l ,h) O I
❑X Burial Date Cemetery or Crematory
February 19, 2014 Pine View Cemetery
CI Entombment Address
El Cremation Quaker Road, Queensbury, , NY 12804 _
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
O Date Point of
N ❑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 StaffordFuneral Home 01443
1 Address
• 53 Quaker Road, Queensbury,NY 12804
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.
i;:; Date Issued - I e-a.01 Registrar of Vital Statistics
(signature)
:iiiF District Number 5 7 a Place Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 2/1 9/1 4 Place of Disposition Pine View Cemetery
111
(address)
N Huron 18 A 2
re (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premis Connie L. Goedert
`Z (please print)
Signature 4..Ai�p, /td22,-(:, Title Superintendent
(over)
DOH-1555(02/2004)