Rummel, Susan ' t NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
'`% Name First Middle Last Sex
Susan Marie Rummel Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 2, 2015 71 War or Dates
=f Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause n Accident Ell Homicide Ti Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
I
``' Address
T' Death Certificate Filed District Number Register Nu r
City, Town or Village Glens Falls, NY 5601 a
❑x Burial Date Cemetery or Crematory
❑Entombment June 8, 2015 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N ❑Transportation Shipment
'p by Common Destination
Carrier
11
Disinterment Date Cemetery Address
Ti Reinterment Date Cemetery Address
4-
4: Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
'`1 Address
31 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains des 'bed bo e% icated.
'!%a Date Issued ex/it Y/2o!S 1
Registrar of Vital Statistics iL1)J �
r / (signature)
District Number 60/ Place (/I is, /VY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 6/8/201 5 Place of Disposition PineView Cemetery, Queensbury, NY
Ili
(address)
Cl) Erie 9D 1
re (section) (lot number) (grave number)
QName of S ton or Person in Charge of Premises cnnn i e T. GoedPrt
Z (please print)
Signatur 12/4/ ..e Tit ( LJt
(over)
DOH-1555(02/2004)