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Cameron Susan Marie NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Susan Marie Cameron Female Date of Death Age If Vetera�ofU.S.Armed Forces, 02/23/2020 61 Years War or Place of Death Hospital,Institution or WCity,Town or Village Warrensburg Town Street Address 353 Schroon River Road,Warrensburg Town,New York 12885 p Mannerof Death ©Natural Cause Accident Homicide Suicide Undetermined Pending (Wj Circumstances Investigation QW Medical Certifier Name Title Bryan Smead MD Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Warrensburg 5660 4 Burial Date Cemetery,Crematory or Facility Name 02/25/2020 Pine View Crematorium Entombment Address X❑Cremation Queensbury Town, New York Donation z Removal Date Place Removed and/or and/or Held H Hold Address Cl) O (L Date Point of fA ❑Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address 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 Address cc W n Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/25/2020 Registrar of Vital Statistics (PameCa 91 LCoyd(E(ectronicaCCy Signed (signature) District Number 5660 Place Warrensburg, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Z/2010 Place of Disposition M (address) W cc cc (section) (lot number) (grave number) 23 Name of Sexton or Person in Charge of Pr raises rw L Z (p ase print W Signature Title DOH-1555(o7/18)p 1 of 2 + ' e Public Health Law Sec. 4145(2b) 0 ,�."30 3 71. Receipt IA Human remains of delivered on , 20 I Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#