Huntington, Susan f N �}
NEW YORK STATE DEPARTMENT OF HEALTH �'f g
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan Alice Huntington Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/02/2014 57 years War or Dates
• Place of Death Hospital, Institution or
W City, Towm yillaa07.ixx Glens Falls Street Address Glens Falls Hospital
a Manner of Death❑NJatural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
iiiCircumstances Investigation
W Medical Certifier Name Title
a Frances C Rollinger M D
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, TovvRw('il XX Glens Falls 5601 3
❑Burial Date Cemetery or Crematory
['Entombment Pine View Crematorium
Address
❑Q, emation Queensbury, NY 12804
Date Place Removed
2❑Removal and/or Held
and/or Address I;,
fl)
Hold
O Date Point of
ki 0 Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
Address
11 Algonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tr
Lu
fl` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/03/2014 Registrar of Vital Statistics LA) C&A.4-'v- _ v
)(signatu
District Number 5601 Place Glens Falls/ N V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Lit Date of Disposition ( /&,I►I Place of Disposition ?nt,UikJ o(�
W (address)
CO
CC (section) (lot number) (grave number)
0
Ci Name of Sexton or Perso in Charge of remises i, r ,S/w'fi
2pl ase print)
Signature Title CRPli t
(over)
DOH-1555 (02/2004) '