Collins, Jacqueline NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jacqueline Ann Collins Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 29, 2015 72 War or Dates
• Place of Death Hospital, Institution or
• City, Town or Village Moreau Street Address 30 Hilton Drive
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
o , Circumstances Investigation
iii Medical Certifier Name Title
s Gerald F Abess M.D.
Address
3 Irongate Center
: a Death Certificate Filed District b ReOpiNumber
City, Town or Village
❑Burial Date Cemetery or Crematory
October 1, 2015 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I
• _; Permit Issued to Registration Number
,a: Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
t 4; Remains are Shipped, If Other than Above
S Address
AZ
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:: Permission is hereby ranted to dispose of the human remaaii describAi a?.ye as indicated.
Date Issued 2 /S—Registrar of Vital Statistics (,G I/ / /
(sature)
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District Number j — Place jom
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
W Date of Disposition (o f y hr Place of Disposition link ,./ rfalkti-tor../
2 (address)
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Qre (section) Pff(lot numb epl (grave number)
Name of Sexton or Person in Charge of Premises `fir Ji,niti.
Z (please print)
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Signature A Title I ►fa
(over)
DOH-1555(02/2004)