Dennison, Susan NEW YORK STATE DEPARTMENT OF HEALTH 411 l '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan Marie Dennison Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 2, 2011 60 War or Dates
F- Place of Death Hospital, Institution or
ujCity, Town or Village Hudson Falls Street Address 106 Oak Street
W
W Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
James North, M.D
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed _J�l�-d�¢vx. �i..c� District S Number Register Number
City, Town or Village 7�1p co
❑Burial Date Cemetery or Crematory
October 4, 2011 Pine View Cemetery
❑Entombment Address
®Cremation Quaker Rd, Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
"i= Hold
Date Point of
• ❑Transportation Shipment
ft) by Common Destination
Ci Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
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
I— Remains are Shipped, If Other than Above
2 Address
CC
W
' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued d 3, // Registrar of Vital Statistics m0� -
(signature)
District Number 5-' , Place (J..it,e, �, z , /16 /a8;gyp
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1Q-5- it Place of Disposition IRhe Cr-9WICCLC �'�►�
(address)
(section II (lot number) (grave number)
O Name of Sexton or Person in Charge f Premises I i mn`ct 1 uyle 'e
(please print)
W Signature Title ("Iv'c��oir SSA- .
(over)
DOH-1555 (02/2004)