Delaney, Susan r't.,)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
' Name First Middle Last Sex
Susan Jane Delaney Female
�,, Date of Death Age If Veteran of U.S. Armed Forces,
May 24, 2018 52 War or Dates
— Place of Death Hospital, Institution or
j City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
LitCircumstances Investigation
W Medical Certifier Name Title
. Gerald F Abess MD,
'P< Address
3 Irongate Ctr. Glens Falls, NY 12801
4 Death Certificate Filed District Number Register Number
r City, Town or Village J�C) 01
❑Burial Date Cemetery or Crematory
May 30, 2018 Pine View Crematorium
❑Entombment Address
.wit:®Cremation Quaker Road Queensbury,NY 12804
`r Date Place Removed
2k Removal
and/or and/or Held
t Hold Address
Date Point of
f ❑Transportation Shipment _
by Common Destination
Carrier
E El Disinterment Date Cemetery Address
❑ Reinterment
Date Cemetery Address
y
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
II^-., Remains are Shipped, If Other than Above
". ' Address
Ws
W0.
, Permissionis herebygranted to dispose of the human remains described above as indicated.
/ Registrar of Vital Statistics --I
Date Issued S 7'� , !� ��-'tn'`Q
�_ (signature)
District Number 560 Place 6 S 1 S ))
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 05/30/2018 Place of Disposition Quaker Road Queensbury,NY 12804
X (address)
at
Ca
te (section) (lot number) (grave number)
gName of Sexton or Perso in Charge of Premises /� J1i
i(please print)
Signature4 Title f 9 MIL
(over)
DOH-1555 (02/2004)