Collins, Andrew '34645
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
�w< Name First Middle- , A Last Sex
Andrew Bernard Collins Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 27, 2011 72 War or Dates
s Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 99 McCrea Street
Manner of Death a Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
1 Medical Certifier Name Title
lb
• Ageel A. Gillani, M.D. Dr.
` `' Address
102 Park Street Glens Falls, NY 12801
` Death Certificate Filed District be Registeber
_; City, Town or Village �j
�` Date Cemete or Crematory
0 Burial December 30, 2011 Pine View
0 Entombment Address
1Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
01 by Common Destination
fit; Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he by granted to dispose of the human _ins described ove a indicated.
Date Issue / Registrar of Vital Statisti
(signs ure)
District Numbe / Place WY-__I;GZ-1--0-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/30/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
:0 (section) i (lot numb (grave number)
* Name of Sexton or Person in Charge of Premises
r,s{u�ur C�hrt�
I' 1 (please print)✓t
Signature Title (�Vm,�T�
(over)
DOH-1555 (02/2004)