Picard, Susan NEW YORK STATE DEPARTMENT OF HEALTH .''. s : u w
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan Picard Male
Date of Death Age 44 If Veteran of U.S.Armed Forces,
1. June 30, 2017 7° War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Skenesborough Harbor Apartments
0 Manner of Death a Natural Cause 0 Accident D Homicide nSuicide ❑Undetermined n Pending
W Circumstances Investigation
U Medical Certifier Name Title
W M. Scovner MD
Q Address
Main Street Poultney Vermont
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall 6.--7,2 7 .5 -
❑Burial Date Cemetery or Crematory
July 3, 2017 Pineview Crematorium
❑Entombment Address
2 0 Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
and/or Address
l' Hold
0 Date Point of
0 El Transportation Shipment
Da by Common Destination
Carrier
Date Cemetery Address
af Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
Ce
W Address
II
Permission is hereby granted to dispose of the human remains desc ' d above as indicated\
Date Issued 7—03-2i/7Registrar of Vital Statistics _(tt/e , D G� �-.-1_
(signature)
District Number s 7 ....i Place Whitehall,New York
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 07/03/2017 Place of Disposition Pineview Crematorium
2 (address)
tU
40
Z0 (section) lot number) c. (grave number)
Name of Sexton or Person in Charge of Premises t A r, r y.nrPt-
UI (ple a print)
SignatureP 2
Title 14.11#
(over)
DOH-1555 (02/2004)