Collin, Shirley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
` Name First Middle Last Sex
Shirley M.Collin Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/02/2017 95 Years War or Dates
Place of Death Hospital, Institution or
W_ City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
ifl Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined O Pending
W Circumstances Investigation
0.
tu Medical Certifier Name Title
1:11, Nawed Siddiqui MD
Address
,t 319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 50
®Burial Date Cemetery or Crematory
11/07/2017 Pine View Cemetery
❑Entombment Address
Cremation Queensbur_y Town,-Now-York--
Date Place Removed
Removal and/or Held
0❑and/or
Address
-= Hold
VI
0 Date Point of
J Transportation Shipment
G` by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
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 11/06/2017 Registrar of Vital Statistics Ai}nee'Mahoney Etectronwaay Sweet
(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:
Z
W' Date of Disposition Place of Disposition _
(address)
W
CO (section) (lot number) (grave number)
p' Name of Sexton or Person in Charge of Premises
(please print)
Signature Title
(over)
DOH-1555 (02/2004)