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Collier, Patrick
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last TM, Patrick Donald Collier Date of Death Age If Veteran of U.S. Armed Forces, 10/08/2019 64 Years War or Dater - Place of Death Hospital, Institution or WCity, Town or Village Fort Edward Village Street Address 9 Factory Street, Fort Edward Village, New York 12828 p Mannerof Death Natural Cause Accident Homicide Suicide ❑ Undetermined © Pending W Circumstances Investigation U W Medical Certifier Name Title Robert Lemieux Coroner Address 415 Lower Main Street, Hudson Falls Village, New York 12839 Death Certificate Filed District Number Register Number City, Town or Village Fort Edward 5755 81 Burial Date Cemetery, Crematory or Facility Name Entombment 10/10/2019 Pine View Crematory Address Cremation Queensbury Town, New York Donation Z Removal Date Place Removed O and/or Held ift F and/or . Hold Address Transportation Date Point by Common Shipmee nt Carrier Destination ❑ Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home -Fort Edward 01079 Address 82 Broadway, Fort Edward, New York 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Otherthan Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/10/2019 Registrar of Vital Statistics Aimee Wakoney (ECectronicaCCy Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WWDate J of Disposition 10 10 ill Place of Disposition iu� ✓ lf9rv;rs. „ (address) W (section) number) (grave number) /,/(lot Name of Sexton or Person in Charge of Premises (^ f't'drl� (pl se print) W 0 iZs T z Signature Title DO H-1555 (07/18) p i of 2 Public Health Law Sec. 4145(2b) s 012590 Receipt Human remains of delivered on `_ , 20 Pine View Cemetery Representing a funeral home named on burial permit Official Funeral Directors Reg. or License