Colby, Simone NEW YORK STATE DEPARTMENT OF HEALTH it 1 .
t .4 ' Burial - Transit Permit
Vital Records Section[
Name First Middle Last Sex
Simone M. Colby 1 Female
Date of Death I Age If Veteran of U.S. Armed Forces,
03/27/2013 164 War or Dates
Place of Death Hospital, Institution or
City,Town or Village NORTH CREEK j Street Address Adirondack Tri County Health Care Center
C3 Manner of Death O Natural Cause El Accident Homicide ❑ Suicide n Undetermined 0 Pending ,
ILI Circumstances investigation
L U Medical Certifier Nape/ i // (�y1
/444ciffes,s6Think,
�- u)/ 4 , ( '7 4).'s I
Death C-a ficate Filed District Number 6.6 �� I Register Numbers
Cit Tow. or Village q25,/_,-! De) . i
0 Burial Date or C,reatoryl /�
04/01/2013 6s�fz� (/G-p�C/ [ �-�ma zo��r�v�
❑Entombment Address dt )--,09//--IX-i.A./ ./( -
�/�� G�®Cremation ����!� j /
Date Place Removed
z I I Removal and/or Held
E LJ and/or Address
Hold
09 Date Point of
Oo 0 Transportation Shipment
t , by Common Destination
Q Carrier
0 Disinterment Date Cemetery Address in
Reinterment Date Cemetery Address
Permit Issued to 1 Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. I 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
MAddress
LLf'
I" Permission is hereby granted to dispose of the human remain describ o indicated.
Date issued 6 3� /
, -J� /l.Registrar of Vital Statistics YSw-e �c n
._ /� /b (signature)
District Numbers S j Place /0 otfh d F V e h/iS c�v�
I certify that the remains of the decedent identified above were disposed of in rraccordance with this permit on:
W` Date of Disposition N 3- 3 Place of Disposition FeeU41 Cr crlv^..
M (address)
W
(section)
C lot number)
�+ (grave number)
0 Name of Sexton or Per on in Charge of Premises L r wt.) �3eh'�
Z ,(plea.e print)
Ul Signature Title ( Ih ii:v1-0e,
(over)
DOH-1555(02/2004)