Columbetti, Catherine a ]
NEW YORK STATE DEPARTMENT OF HEALTH -Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
M Catherine M. Columbetti Female
i*i:: Date of Death Age If Veteran of U.S. Armed Forces,
January 18, 2016 95 War or Dates
xi Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 24 Boulevard
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson
:::' Address
' 161 Carey Road,Queensbury,NY 12804
:g:i Death Certificate Filed District Number Register Number
; City, Town or Village Hudson Falls 5726 a2
❑Burial Date Cemetery or Crematory
❑Entombment January 19, 2016 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
r Hold
CO
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
; ;:y Permit Issued to Registration Number
':;:; Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
rr Address
�40407 Bay Road, Queensbury, NY 12804
: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:.r
Permission is hereby granted to dispose of the human remains described above as indicated.
:*: Date Issued //, c,-/,i/L Registrar of Vital Statistics r a.
rr; (signature)
;Y. District Number 5726 Place Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition j /2i /IL Place of Disposition al UN,,, /i-vroc1cr:�'
2 (dress)
W
N
CC (section) i - (lot number) (grave number)
pp Name of Sexton or Person in Charge f Premises /J,f,a ti1,.af`
Z I (please print)
LU /
Signature { Title -Fi " Ca. wliiaa
(over)
DOH-1555(02/2004)