Scott-Walker, Susie V. NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susie V. Scott-Walker Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 13,2020 69 War or Dates
I— Place of Death Hospital, Institution or
IZ City, Town or Village Mt. Pleasant Street Address Westchester Medical Center
p Manner of Death ❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
V Circumstances Investigation
W Medical Certifier Name Title
Samantha Destefano DO
Address
100 Woods Road,Valhalla,NY 10595
Death Certificate Filed District Number Register Number
City, Town or Village Mt. Pleasant 5957
❑Burial Date Cemetery or Crematory
❑Entombment May 5, 2020 Pine View Cemetery and Crematorium
Address
❑x Cremation 21 Quaker Road, Queensburv, NY
Date Place Removed
OZ ❑Removal and/or Held
and/or Address
Hold
U)
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of eral Home Clark Funeral Home, Inc. 00340
Address
2104 Saw Mill River Road, Yorktown Heights,NY 10598
Name of Funeral Firm"Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
S Address
Ir
W
a
Permission is hereby granted to dispose of the human remains described above as igoicated.
Date Issued 5/4/2020 Registrar of Vital Statistics Af -,
9 (signature)
District Number 3 /5 7 Place Mount Pleasant,New York
I certify that the remains of the decedent identified abo re disposed of in accordance with this permit on:
Z /� I
t.0
W Date of Disposition b -W Place of Disposition r rle �j'U z(Q R ua kart . (�.�IdrGf
W (address)
N
(section i (lot number) (grave number)
Op Name of Sexton or Person in Charge of P emises �/Z� D
IZ (please print)
Signature Title IZ-
(over)
DOH-1555 (02/2004)
is
Public Walth Law Sec. 4145(2b) 1,3 f
Receipt
Human remains of ? °• delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#