Disbrow, Susan ( V D
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan E. Disbrow Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 8,2012 86 War or Dates
Place of Death Hospital, Institution or
tZ City, Town or Village Hague Street Address 417 Split Rock Road
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Ci Dr.Nancy Carney _
Address
IIHHN,Wrg.,NY 12885
Death Certificate Filed District Number _ Register Number
City, Town or Village Hague (
❑Burial Date Cemetery or Crematory
❑Entombment May 11,2012 Pine View Crematory
Address
Li Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
O and/or Address
F Hold
N
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 1 Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
W
a
Permission is hereby granted to dispose of the huma remains described above as ind' ated.
Date Issued 31 �n)7 Registrar of Vital Statistics On i t`-
(signature)
District Number ' Place Hague
I certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
w Date of Disposition 6(I.t((j Place of Disposition f1LA.4 C04 "
(address)
W
N
(section) (lot number) r (grave number)
O
Z �
Name of Sexton or Person in Charge o Premises j 61441-
W (please print)
A
Signature / Title Oki* Tii,
9
(over)
DOH-1555 (02/2004)