Dicks, Susan NEW YORK STATE DEPARTMENT OF HEALTH 5
Vital Records Section a ,_ir Burial - Transit Permit
;> , Name First Mi, Last Sex
<%> Susan Jane Dicks Female
:i Date of Death Age i -n of U.S. Armed Forces,
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October 14, 2016 74 r or Dates
'r . Place of Death " •spital, Institution or
City, Town or Village Luzerne et Address 253 Howe Road
Manner of Death I XI Natural Cause ident ❑Homicide n Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name ' Title
': Address
,: Death Certificate Filed CT District Number Register Number
V City, Town or Village Li; 2_ :r
c a'>c, 5'd,5-L 1 Z
❑Burial Date Cemetery or Crematory
October 18, 2016 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO [-I Removal and/or Held
and/or Address
H Hold
N
O Date / Point of
O.
n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Nr Permit Issued to Registration Number
.4 Name of Funeral Home Regan Denny Stafford Funeral Home 01443
f Address
%-: 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I.: Remains are Shipped, If Other than Above
Address
-i Permission is hereby granted to dispose of the human ains described above as indicat
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Date Issued /Q-/d °�d/bRegistrar of Vital Statistics ,c.a.� 72117
y�. (signature
District Number � 54, Placeo/_. ? Ao ���_e,
I certify that the remains of the decedent identified above w dis osed of in accordance with this permit on:
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Z g 0 f Vf halm"•.
W Date of Disposition j0 III��(, Place of Disposition one
rd (address)
W
O (section) -(lot number (grave number)p Name of Sexton or Person in Charge of Premises Aro y S"1/11
Z (pl ase print) �7'
W GC Title (REMORA_
1b` _
Signature
(over)
DOH-1555(02/2004)