Colomb, Timothy NEW YORK STATE DEPARTMENT OF HEALTH ; L I
Vital Records Section f ,, Burial - Transit Permit
Name First w Midde Last Sex
Timothy L. Colomb Male
Date of Death Age If Veteran of U.S.Armed Forces,
April 24, 2013 121 War or Dates Yes 1969-1971
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death E Natural Cause Li Accident El Homicide Suicide D Undetermined D Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Eric Goe MD
a Address
65 Elm Street Glens Falls New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5 £ Q I I -1 Cl
0 Burial Date Cemetery or Crematory
April 2013 Pine View Crematorium
❑Entombment Address
▪ n Cremation 21 Quaker Road Queensbury New york 12803
Date Place Removed
0 ID Removal and/or Held
- and/or Address
I' Hold
0 Date Point of
0 ETransportation Shipment
D. by Common Destination
Carrier
Date Cemetery Address
0 ❑Disinterment
ReintermentEl
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
re Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued `► / Z 611,3 Registrar of Vital Statistics CA)y`'`Q viL
(signature)
District Number S 6 0 ( Place Glens Falls,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition (fr7 (3 Place of Disposition ZUll('.1 Cv tofiu,`
2 (address)
(.0
0 (section) tuber) (grave number)
0
O Name of Sexton or Person in Charge of P emises 4Ioti
,g g+y,�if
W (pse print)
Signature Title CVO') V.
(over)
DOH-1555 (02/2004)