Cook, Susan NEW YORK STATE DEPARTMENT OF HEALTH
r Burial - Transi 'ermit
Vital Records Section '4
-- Name First Middle Last Sex
Susan K. Cook Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 23, 2011 80 War or Dates
LPlace of Death Hospital, Institution or
u City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Natural Cause Accident ❑ Homicide ❑ Suicide 1-1 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Robert W Sponzo MD,
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Nil •'. Regis b
City, Town or Village i1
❑Burial Date Cemetery or Crematory
December 27, 2011 Pine View Crematorium
r ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z ❑ Removal and/or Held
0 and/or Address
F= Hold
co Date Point of
p. ❑Transportation Shipment
0) by Common Destination
a 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
- Remains are Shipped, If Other than Above
• Address
ir
I:lI
• Permission is hereby granted to dispose of the human remains desc • o as • ' ed.
Date Issued /,ZA7 t0/' Registrar of Vital Statistics
(signature)
District Number SbO/ Place_ �,/-4o !/, xy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W'' Date of Dispositionta-aq-16k Place of Disposition (P1l1p V I"e4) Cf 'eYrta,-Lar ►vw1
(address)
ill
Ce (section) (lot
number) (grave number)
l
Name of Sexton or Person in Char a Premises I onizi 8rLi eeasin (please print)
• Signature61 ,, of
Title CrevvIccto 4S's,1
(over)
DOH-1555 (02/2004)