Balch, Susan zr33.4
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan M. Balch Female
Date of Death Age If Veteran of U.S. Armed Forces,
04 / 17 / 2018 72 War or Dates N/A
14 Place of Death Hospital, Institution or
. City, Town or Village Milton Street Address Gateway House of Peace
LLI0 Manner of Death®Natural Cause —Accident Homicide E Suicide C�Undetermined Pending
ILI Circumstances Investigation
ta
at Medical Certifier Name Title
Q Paul E. Gebhard, Jr. MD
ni Address
1 West Ave, Saratoga Springs, NY 12866
Death Certificate Filed District Number ` 156 ` Register Number
<> City, Town or Village Milton I
>=[; Burial Date Cemetery or Crematory
> 04 / 19 / 2018 Pine View Crematory
LI Entombment
Address
eiii
Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
`,„ Date Point of
0 Transportation Shipment
by Common Destination
igil Carrier
0 Disinterment Date Cemetery Address
Mi
Q Renterment Date Cemetery Address
lip Permit Issued to ' Registration Number
NiName of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Sp. , NY 12866
'' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
It
itt
Permission is hereby granted to dispose of the hums :ills described . • as indi = _
Date Issued y\\Cts\\ Registrar of Vital Statist s y_ s ' �Alteib. _
iiM signature)
District Number -\S(p \ Place Milton , New York
.; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i - �
ILI Date of Disposition 1J 0 t ( Place of Disposition 1'�r.0..."." /r...e}d,✓
'y (address)
1
fr (section) f l (lot number (grave number)
Name of Sexton or Person in harge of Pre ises `"n, �' j^'
it
(ilease print) •
Signature Title
(over)
DOH-1555 (02/2004)