Susalka, Andrew9106
NEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial -Transit Permit
Name First Middle Last
Sex
Andrew John Susalka
Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
09/07/2019
67 Years
War or Dates
ZPlace
of Death
Hospital, Institution or
UJI`p
City, Town or Village Queensbury Town
Street Address 3 Ames Place, Queensbury Town, New York 12804
Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
U
Circumstances Investigation
LLI
Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9, Lake George Town, New York 12845
Death Certificate Filed
District Number
Register Number
City, Town or Village Queensbury
5657
133
Burial
Date
Cemetery, Crematory or Facility Name
Entombment
09/11/2019
Pine View Crematory
Cremation
Address
Queensbury Town, New York
Donation
Removal
Date
Place Removed
OZ
and/or
and/or Held
f—
N
Hold
Address
O
IL
CO)
❑ Transportation
Date
Point of
p
by Common
Shipment
Carrier
Destination
Disinterment
Date
Cemetery Address
Reinterment
Date
Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Maynard D Baker Funeral Home
01130
Address
11 Lafayette St, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
g
Address
IIx
W
9'
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/11/2019 Registrar of Vital Statistics CarnCrnexldegarde (Barger (Ek tronrcalTy Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
LLI
Date of Disposition 13) Place of Disposition s
2(address)
W
IIX N
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 4r'i L% NT
Z
W
( ase print/
Signature Lip Title
DO H-1555 (07/18) p 1 of 2
-i(2b) i . ..I
Public Health Law Sec. 414:) 012532
Receipt
Human remains of 12.
"�Q delivered on 20-L
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License #