DeVivo, Colena NEW YORK STATE DEPARTMENT OF HEALTH • - 's _ Transit Permit
Vital Records Section Burial
Name First Middle Last ' Sex
Colena DeVivo Female
Date of Death Age I If Veteran of U.S. Armed Forces,
July 9, 2011 74 War or Dates
1.. Place of Death I Hospital, Institution or
W City, Town or Village Saratoga Springs Street Address Saratoga Hospital Nusrsing Home
p Manner of Death X Natural Cause n Accident I I Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Marianne Mustafa MD
Address
211 Church Street, Saratoga Springs,NY
I
Death Certificate Filed District Number ' Register Number
City, Town or Village Saratoga C /
❑Burial Date I Cemetery or Crematory
July 11,2011 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
F' Hold
N
0 Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number .
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
F_ Remains are Shipped, If Other than Above
2 Address
Ce
a
Permission is hereby granted to dispose of the human remains d cribed abov as indicated
Date Issued // �/� Registrar of Vital Statistics ! -
�// (signature)
District Number V�/ Place Saratoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1-1$' 1% Place of Disposition M/li lev `et".40f Mrs.
2 (address)
W
co
cc
(section) (lot bar) (grave number)
Op Name of Sexton or Per in Charge of P mises (1r>>}ft,r it.1K
Z (please print)
W Signature Title CeinviIYTo(1L
(over)
DOH-1555(02/2004)