Cottrell, Cory NEW YORK STATE DEPARTMENT OF HEALTH , ...1l 'tt C I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cory K. Cottrell
Date of Death Male
Age If Veteran of U.S. Armed Forces,
October 5, 2014 21 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address West Mountain Road
Manner of Death❑ Undetermined Pending
Natural Cause X❑ Accident ❑ Homicide ❑ Suicide ❑ ❑
Circumstances Investigation
Medical Certifier Name Title
Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 56SI { (o
❑Burial Date Cemetery or Crematory
October 9, 2014 Pine View Crematory
❑Entombment Address
®Cremation
Quaker Road Queensbury,NY 12804
" =❑ Removal Date Place Removed
and/or and/or Held
- Hold Address
Date Point of
a ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
• Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
Address
•
Permission is hereby granted to dispose of the human re ain escribe; - as i;�,icated.
.g Date Issued i D —i —ap,4 Registrar of Vital Statistics 9 - / /II
(signature)
District Number 5i Place 4cLo_y, p
4
4 I certify that the remains of the decedent identified abo - were disposed of in acco •-• e with this permit on:
- Date of Disposition 10/09/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot yniitiZ (grave number)
Name of Sexto .r Per-. large •f Premises '4
(pleas print)
-' Si natur-\,Afar d
9 w- i„ Title
(over)
DOH-1555(02/2004)
C'i7TTRF.LL Lot NO. 2 9R
Address 36 Homer Ave , QuPPnshury, N.Y 1 7RQ4 Section No.
Owner Plot
F.rit- rnttr.Q31 Erie
Date 6/3/2015
Apprnx 32 Sq_ Ft.
Superficial ft.
Location
Ermnrieri nn Nortb by Path, South by Vacant
East by Vacant and West- by Variantirntt-rPl l
Corner Posts
Remarks ( '-t8) 6R-l_1 Q01 S lei. - (S, - l 9O( ettC C (2-1/
Deed No. (and changes) 3 9 0 5
Payment Record
Paid. in Pull, S4pn
Record of Interments fit. (O \ raCiVC5
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NAME Cottrell, Cory
Age: 21
Cause:
Lot Owner: Eric and Jill Cottrell
Lot # 22A, Erie
Crave # 2
Case # Ceramic Urn
Died: 10/10/2014
Interred: 7/3/2015
Undertaker: