Colvin, Cynthia Jean -figsz
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cynthia Jean Colvin Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/22/2023 56 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Kingsbury Town Street Address 132 Farley Road, Kingsbury Town,New York 12839
IIJ
p Manner of Death ❑^ Natural Cause Accident []Homicide []Suicide Undetermined []Pending
Circumstances (Investigation
W Medical Certifier Name Title
CI Aimee Mcmaster NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Kingsbury District Number Register Number
City,Town or Village 5762 32
[]Burial Date Cemetery,Crematory or Facility Name
10/24/2023 Pine View Crematorium
[]Entombment Address
[]Cremation Queensbury Town,New York
Donation
o Removal Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
N[]Transportation
by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
Date Cemetery Address
C Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
}� Remains are Shipped,If Other than Above
2 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/24/2023 Registrar of Vital Statistics Cynthia Bardin(ECectronica1TySigned)
(signature)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF—
Z Date of Disposition /0J114173 Place of Disposition j'�, k,,r��.... (�'at /►'lArtfre—
W
2 (address)
W
N
Q (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises
rd
Z (pi se se pr/ntILI
Signature Title tC•n1417)n
DOH-1555(07/18)p 1 of 2
71.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of - delivered on , 20
Pineew Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#