Collard, June t 27o
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
June M. Collard Female
Date of Death Age If Veteran of U.S.Armed Forces,
November 25, 1980 30 War or Dates NA
l. Place of Death Hospital, Institution or
Z City, Town or Village Minerva Street Address Wilson Road
pManner of Death I I Natural Cause Accident X Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O Michael Sikirica ME
Address
50 Broad St.,Waterford,NY 12188 _
Death Certificate Filed District Number Register Number
City, Town or Village T/O Minerva,NY 1557
❑Burial Date Cemetery or Crematory
May 24,2011 Pine View Crematory
❑Entombment Address
El Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
U)
O Date Point of
• Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
Address
tY
O. Permission is hereby granted to dispose of the human ains.described above as indicated.
Date Issued 5I 2-+-E1 i l Registrar of Vital Statistics
(signature)
District Number 1557 Place T/O Minerva,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition S -2b Place of Disposition . ; t U ti„a fl {of ivy
(address)
W
U
(section) A (lot nu r) (grave number)
pName of Sexton or Person in Ch rge of Premises
(Please print)
W
Signature Title C r.inpr oit
(over)
DOH-1555(02/2004)