Collard, Mina (-
NEW YORK STATE DEPARTMENT OF HEALTH t :
Vital Records Section Burial - Transit Permit
Name First f' Middle Last I Sex
Mina . May Collard Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 29, 2011 76 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls j Street Address Glens Falls Hospital
pManner of Death X Natural Cause [ ]Accident I I Homicide Suicide Undetermined Pending
W Circumstances 'Investigation
W Medical Certifier Name Title
O Daniel Way, MD
Address
North Creek Health Center,Ski Bowel Rd.North Creek,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 ` 1 1 La'1
❑Burial Date Cemetery or Crematory
November 1, 2011 Pine View Crematorium
❑Entombment Address
Ei Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
OI 1 Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NI 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery AddressI. I
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home , 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
O.
Permission is hereby granted to dispose of the human remains d scrri ed bo v s indicated.
Date Issued /�lp//l// Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
W Date of Disposition i1 it(1‘ Place of Disposition tIt 1 ( ' 4oriw-
(address)
W
N
(section) (lot nun ) (grave number)
pn
p
• Name of Sexton or Pers in Charge Premises �t�s� r J Pell'
Z (please print)
W Signature _ Title CV cPIATdt2
(over)
DOH-1555(02/2004)