Klass, Colleen NEW YORK STATE DEPARTMENT OF HEALTH it 5II Vital Records Section Burial - Transit Permit
7 Name First Middle Last Sex
Colleen S. Klass Female
Date of Death If Veteran of U.S. Armed Forces,
December 16,2016 j ` 4 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Bolton Street Address 15 Nellie Lane
Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
tU, Medical Certifier Name Title
Timothy E.Murphy
Address
52 Haveland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
=" City, Town or Village Bolton 5650 ?0
❑Burial Date Cemetery or Crematory
December 19, 2016 Pine View Crematory
El Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
': ' Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
=`, 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
2a Address
Permission is hereby granted to dispose of the human remains describ d abo as ind'cated.
,, Date Issued /Z/ZC 201(a Registrar of Vital Statistics
(signature)
District Number 5650 Place I OL'3 n vt bU I+0 ►1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Ill 2.Ll1 , 'Place of Disposition nit St._ C�ctin�.to('
2 (address)
W
Cl)
W (section) // (lot number) (grave number)
pName of Sexton or Person in Charge of Premises I1r iMl,�r +^ �
Z lease print)
W Signature Title !'C:Dirt Vit.
(over)
DOH-1555 (02/2004)