Collard, Christine L NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records —
Name First Middle Last Sex
Christine L.Collard Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/03/2022 73 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 1004 E River Drive, Lake Luzerne Town, New York 12846
p Manner of Death 0 Natural Cause Accident ❑Homicide Suicide Undetermined nPending
UCircumstances l 'Investigation
WQ Medical Certifier Name Title
Matthew Pender MD
Address
35 Gilbert Street,Cambridge Village, New York 12816
Death Certificate Filed Town Of Lake Luzerne District Number Register Number
City,Town or Village 5656 16
Burial Date Cemetery,Crematory or Facility Name
08/06/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,Warren, New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
to
0
a Date Point of
N ElTransportation
CI by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne, New York 12846
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/05/2022 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed)
(signature)
District Number 5656 Place Town Of Lake Luzerne
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F—
Z Date of Disposition C-4._2pZZ Place of Disposition IP, oe ✓;e..4.4f Cr-t ,t +p,—
W
2 (address)
W
Cl)
CC (section) n (/ (lot numb / (grave number)
0 Name of Sexton or Person in Charge Prem. es l?Y'1 ink .- D��
z (pleas print)
W Signature _� �?r,
I � � Title oP sky—
DOH-1555(07/18)p 1 of 2
I
Public Health Law Sec. 4145(2b)
Receipt
1
1
1 Human remains of delivered on , 20
Pine Vi9{wCemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#