Collins, Judith Anne NEW YORK STATE DEPARTMENT OF HEALTH `ty
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last
Sex
Judith Anne Collins Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/14/2022 J79 Years War or Dates
Place of Death I Hospital,Institution or
Z City,Town or Village Wilton Town Street Address 21 Carr Road 101,Wilton Town,New York 12866
Manner of Death a Natural Cause ❑Accident Ej Homicide ❑Suicide ❑Undetermined ❑Pending
W
Circumstances Investi•ation
la Medical Certifier Name Title
Mark Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Wilton District Number Register Number
City,Town or Village 4569 34
111 Burial Date Cemetery,Crematory or Facility Name
06/15/2022 Pine View Crematory
II Entombment Address
Cremation Queensbury Town,New York
■Donation
0Z ■Removal Date Place Removed
F and/or and/or Held
N Hold Address
0
to Transportation
by Date Point of
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
.Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f— Remains are Shipped,If Other than Above
Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/15/2022 Registrar of Vital Statistics Susan ea/lunn(!EIctrtmic Sign.!)
/signature)
District Number 4569 Place Town Of Wilton
Icertiiy that the remains of thedecedent identified above were disposed of in accordance with this permit on:/Date of Disposition l I``tl Place of Disposition U
/address
W
(section) 1 (lot number/ (grove number)
S Name of Sexton or Person in rile of Premises
1p/litise print)
W Signature Title vvvv /'off
DOH 1S55(0746tptofa
Public Health Law Sec. 4145(2b) f
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#