Mallory, Susan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan Ann Mallory Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 18, 2013 60 War or Dates
f- Place of Death Hospital, Institution or
LiiCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Ci Manner of Death rzrl
v..i Natural Cause Accident Ei Homicide 0 Suicide nUndetermined ri Pending
Circumstances Investigation
W' Medical Certifier Name Title
C Scott Biasetti, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Nu ber Register Numb r
City, Town or Village Lan
®Burial Date Cemetery or Crematory
r= OS) 1 1 20 t ST. ALPHONSUS CEMETERY
❑Entombment Address
,[]Cremation Town of Queensbury,NY
Date Place Removed
z ri Removal and/or Held
and/or Address
Ei Hold ST. ALPHONSUS CEMETERY
TB
Date Point of
a. 0 Transportation Shipment
(!) by Common Destination
Q Carrier
Disinterment Date Cemetery Address
Re'intermen+ I Date ' Cemetery Address
1 -
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I - Remains are Shipped, If Other than Above.
2 Address
tU
0' Permission is h reby granted to dispose of the human remains described above as indicated.
Date Issued 5 Registrar of Vital Statistics a_ "e_ 1)1 - --/
(signature)
District Number 6 �7� Place �,�� �i�x
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition 134 t 3 Place of Disposition 5 4 Ai P1-)p,St. s Q U e e%t b,^y Alf`!
(address) ,Z
111
CO
te (sectioI (lot number) (grave number)
C Name of Sexton or Person in Charge of Premises i t'44 k
Q (please print)
W Signature Title PrI ay..A`I
(over)
DOH-1555 (02/2004)