Sutliff, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
▪ �s Helen Hazel Sutliff Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 15, 2015 86 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
Cr Manner of Death 0 Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
all
Circumstances Investigation
Ull Medical Certifier Name Title
CI Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Reis er.Number
City, Town or Village 5601
Burial Date Cemetery or Crematory
® March 20, 2015 Pine View Cemetery
r, ❑Entombment Address
OCremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
❑ Removal
and/or and/or Held
Address
p_ Hold Pine View Cemetery
Date Point of
a. ❑Transportation Shipment
by Common Destination
Carrier
' El Disinterment Date Cemetery Address
N❑ Reinterment
Date Cemetery Address
ow
J44-
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
Remains are Shipped, If Other than Above
• Address
CC
,' Permission is hereby granted to dispose of the human remains described above as indicated.
Registrar of Vital Statistics W ln)
Date Issued 3/ t ? S Re g � ti`°
3 '' (signa ure)
▪ District Number 5601 Place 6(Sz t..s RALIs / N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
?
W' Date of Disposition 03/20/2015 Place of Disposition Quaker Rd. Queensbury,NY 12804
(address)
to 113B Mohawk 1
it: (section)
(lot number) (grave number)
• Name of S on or Person in Charge of Premises (O,JIJIE L, v6GDEf2;
Z (please print)
W Sig natur -�t-e�. b-c�r; C-C Title
(over)
DOH-1555 (02/2004)