Kolka, Janet 41 I Scil
NEW YORK STATE DEPARTMENT OF HEALTH � 'I.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Janet Mary Kolka Female
Date of Death Age I If Veteran of U.S. Armed Forces,
April 5, 2011 1 74 1 War or Dates
� Place of Death ' Hospital, Institution or
Z' City, Town or Village Queensbury Street Address Westmount Health Facility
tU Manner of Death Undetermined Pending
� Natural Cause Accident Homicide Suicide
W Circumstances Investigation
W Medical Certifier Name Titlg
/Y,✓ � J '.
Addressci l e. ^G`e.,or-, t Net
Death Certificate Filed I District Number 1 Re ist.g Number
City, Town or Village Queensbury 5657
❑Burial Date I Cemetery or Crematory
III Entombment April 6, 2011 _ Pine View Crematorium
Address
❑x Cremation 21Quaker Road, Queensbury, NY 12804
Date I Place Removed
Z Removal I and/or Held
O and/or Address
H Hold
N
O Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I _ _
Reinterment Date 1 Cemetery Address
-' Permit Issued to ! Registration Number
1 Name of Funeral Home Singleton- Healy Funeral Home 01622
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
}- Remains are Shipped, If Other than Above
2 Address
CL
W
13.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 14 I co kj) Registrar of Vital Statistics 4<CA___ -
a 4)?91(111
re
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with thik permit on:
WDate of Disposition --1-1' Place of Disposition Zi."0 kW C i-ef nrlife..,
W (address)
co
re (section) i (lot number,-. (grave number)
QName of Sexton or Person in Charge.of Premises (((,,, f.S�Zff Pna
z P (please print)
W Signature 4 '/V�� Title Ci MA70D
(over)
DOH-1555(02/2004)