Coltey, Florence Ann NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Florence Ann Coltey Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/27/2022 81 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death ❑X Natural Cause EI Accident Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 71
EiBurial Date Cemetery,Crematory or Facility Name
02/07/2022 Pine View Crematory
Ei Entombment -
Address
X❑Cremation Queensbury Town,New York
❑Donation
ZO Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
Cl) 1-1
Transportation
0 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
pI
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/01/2022 Registrar of Vital Statistics Megan.101iin glectronicallj/Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Il—
Z Date of Disposition Place of Disposition Q i►^� IJ!GW G L, 1c��
W
(address)
W
CC
N
(section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises {' ��/ �5 C4.,.5
Z (please print)
W Signature Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#