Coulter, Constance Town of Queensbury
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of: Constance Coulter
were cremated on August 19 20 22 at the Pine View
(Month) (Day)
Crematorium, Queensbury, New York, and these are the cremated remains of said body.
Date of Death August 16 20 22 Age 95
(Month) (Day)
Funeral Home Regan Denny Stafford Registered No. 665
(Authorized Signature)
# Id(DC
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Constance J Coulter Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/16/2022 95 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
Melody Long PA
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 428
▪Burial Date Cemetery,Crematory or Facility Name
08/18/2022 Pine View Crematory
Entombment Address
(Cremation Queensbury Town,New York
▪Donation
ZO❑Removal Date Place Removed
and/or and/or Held
Hold Address
N
O
O. Date Point of
N)❑Transportation
El by Common Shipment
Carrier Destination
ElDisinterment 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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
M Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/18/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 2Z Place of Disposition ,
(address)
W
CC
N
(section) / (lot number) (grave number)
▪ Name of Sexton or Person in Charge of Premises n �l'"`�h1
Z
(pl se print)
W Signature Title « H
RIK
DOH-1555(07/18)p t of 2
I Public Health Law Sec. 4145(2b)
Receipt
P
1
1
1
Human remains of delivered on , 20
1
1
1 Pine View Cemetery Representing the funeral home named on burial permit
1 Official Funeral Directors Reg. or License#
1
COULTER
NAME Constance 0(.7
,Age:Coulter g 95
Lot Owner: Constance Coulter
Lot# Mohican 76 A Grave# 1A
Case: Urn
Died: 8. 1 6.2 2 Interred: 8.2 2.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine V I ew
COULTER
Lot No. 76
kddress 85 Fourth St . , Glens Falls, NY 12801 Section No. A
Dwner Mrs . Constance Coulter Plot Mohican
Date 2/10/92
Approx. 67 Superficial ft. @
Location Bounded on North by Vacant , South by Path, East by Path,
West by Vacant .
corner Posts
Remarks
Deed No. (and changes) 2 410
Payment Record Paid in Full 2/10/92
Etecord of Interments
Charles Howard
Coulter , Sr . 2/10/92 V'Q
S2 - rl-l� to V
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Fonn No. 01