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Collier, Cynthia NEW YORK STATE DEPARTMENT OF HEALTH If II Vital Records Section N. Burial - Tran it Permit '` Name First Midge Last Sex 4 Cynthia Ann oilier Female _ _ Date of Death Age ci, If e ..S. Armed Forces, ' January 11, 2016 v- • Bates Place of Death Hospital, Institution or W City, Town or Village Street Address Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending In Circumstances Investigation In Medical Certifier Name Title 0 Frances Bollinger MD, Address 161 Carey Rd Queensbury, NY 12804 Death Certificate Filed District Number Register Number Q` � City, Town or Village 5(o) ' U �:El Burial Date Cemetery or Crematory January 18, 2016 Pine View Crematorium -.❑Entombment Address }©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal z and/or and/or Held 4' Address Hold Uf Date Point of cf. ❑Transportation Shipment CO by Common Destination a Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped, If Other than Above Address CY 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued i 1 1 3 11 b Registrar of Vital Statistics W �ti (signature) District Number 560 , Place ‘ -s V-Ct.\\. 0 y F' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W° Date of Disposition 01/18/2016 Place of Disposition Quaker Road Queensbury,NY 12804 X (address) 11.1 i° (section) /�f (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises C firsitOr SG✓ft ' z �� � (please print) W Signature ,,�/ ...4 (l y l Title aElmeiI►it (over) DOH-1555 (02/2004)