Colby, Jacqueline NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jacqueline Colby I Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/29/2019 61 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Greenwich Town Street Address 10 Sherman Avenue,Greenwich Town,New York 12834
p Manner of Death �Natural Cause Accident Homicide Suicide Undetermined Pending
Lill Circumstances Investigation
0
U1 Medical Certifier Name Title
Susan Dorsey MD
Address
1 West Avenue,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,TownorVillage Greenwich 5757 17
Burial Date Cemetery,Crematory or Facility Name
12/31/2019 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
❑Donation
0 El Removal Date Place Removed
and/or and/or Held
Hold Address
Q
Date Point of
it? ❑Transportation Shipment
by Common
Carrier Destination
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Flynn Bros Inc-Greenwich 00589
Address
80 Main St,Greenwich,New York 12834
Name of Funeral Firm Making Disposition or to Whom
1. 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 12/30/2019 Registrar of Vital Statistics Kellie Blake(Electronically Signed)
(signature)
District Number 5757 Place Greenwich, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1 2 3/— 19 Place of Disposition J0iy1�V rim 4,4 r
(address)
LLI
N (section) of number/ (grave number)
Ir
', Name of Sexton orZPe �i Charge of Premises j r^'�' �"' � ri �
(P/t P
itl Signature Title
DOH-1555(07/18) of 2
Public Health Law Sec. 4145(2b) _ 1,1131-03
Receipt
Human remains of <.,•fB . * delivered on _ , 20,,—
Pik View Cemetery Representing the funeral ho med on burial permit
Official Funeral Directors Reg. � `