Dashnaw, Suzuko NEW YORK STATE DEPARTMENT OF HEALTH
f AOr', Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Suzuko N. Dashnaw Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 6, 2015 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death m
inj Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
U. Circumstances Investigation
ILI Medical Certifier Name Title
CI Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death Certificate Filed District Number Register Nu ber
City, Town or Village Fort Edward 5755 q L
0 Burial Date Cemetery or Crematory
December 9, 2015 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
t Hold
C4 Date Point of
a ❑Transportation Shipment
C by Common Destination
I Carrier
Date Cemetery Address
❑ Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
ffi
IL Permission is hereby granted to dispose of the human e ins descri ed ve s indicated.
Date Issued / / 4:200 Registrar of Vital Statistics Y`
(signat!e)
District Number 5'7 Place-10VA. Ci
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w• Date of Disposition 12/09/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
w
IZ (section) 4.(lot number) (grave number)
ct Name of Sexton or Person in Charge of Pr ises G�r'� seiii-
z
►; A (p ase print)
W Signature Title —
(over)
DOH-1555 (02/2004)