Collins, Christopher tt37
NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section Burial - Transit Permit
Name First Idle Last Sex
Christopher , Collins Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 3, 2013 63 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I I n I I ri1.11 Undetermined n Pending
C Natural Cause Accident Homicide Suicide
Circumstances Investigation
ill Medical Certifier Name Title
In Ac IeL A, 6-Ll-LAnittL
Addres
10� RR *--1 ) L j,,s ; I a g of
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 c I.
❑Burial Date Cemetery or Crematory
July 5, 2013 Pine View Crematory
❑Entombment Address
EI Cremation Quaker Road, Queeensbury,NY
Date Place Removed
Z 0 Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
% L Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tc
a Permission is hereby granted to dispose of the human remains describ above as i dicat .
Date Issued Registrar of Vital Statistics ea4_,�a - G�
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition 71013 Place of Disposition 4hLJ aerto,i,...
2 (address)
cn
re (section) (�lo�tj'umber) (grave number)
pName of Sexton or Person in Charg of Premises Xi) t1... Swl4-
tZ (p ase print)
Signature AL_ Title rat- r
1 (over)
DOH-1555(02/2004)
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