Collins, Carol Anne 14'0 ItlNEW YORKSTATE DEPARTMENTOF HEALTHBurial - Transit - 1(.4
Bureau of Vital Records
Name First Middle Last Sex
Card Anne Collins Female
Date of Death Age If Veteran of US.Armed Forces,
05/21/2022 82 Years War or Dates
p. Place of Death Hospital,Institution or
City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
aManner of Death a Natural Cause ❑Accident El Homicide OSuicide Undetermined ❑Pending
W
v Circumstances Investigation
WC Medical Certifier Name Title
Michael Miles MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed Town Of Johnsburg District Number Register Number
City,Town or Village 5655 11
Burial Entombment 05Addres Date Cemetery,Crematory or Facility Name
Addres022 Pine View Crematorium
s
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
O
a Date Point of
(/)❑Transportation
8 by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
ID Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
CC
W
11' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/23/2022 Registrar of Vital Statistics Iran A/Canrstack(fYictronicaQySOle4J
(signature/
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3IZS I lZ Place of Disposition fL(L.. d('<<.
tu
ddressl
W
CO (section) A(lot number/ (grave number)
O Name of Sexton or Person in Charge f remises /n r�� L st tt
z (plea print) `
W Signature Title lMf� '
DOH 1555(07/18)p 1 of 2
0 1 5 7 3 0
Public Health Law Sec. 4145(2b)
Receipt
Human remains of , delivered on , 20• -
1
Pine View Cemetery Representing the funeral home named„on burial permit
Official Funeral Directors Reg. or License#