Ives, Susan NEW YORK STATE DEPARTMENT OF HEALTH' ' ' it 43
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan J Ives Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/20/2013 68 years War or Dates No
1- Place of Death Hospital, Institution or
WCity, T•`,�• sr . SchenectasJ Street Address Ellis
Manner o Beat Natural Cause Li Accident 0 Homicide El Suicide Ell Undetermined ri Pending
vCircumstances Investigation
UJ Medical Certifier Name Title
O
Stephen Piacentine M D
Address
2546 Balltown Rd Suite 300, Schenectady, Ny 12309
•
Death Certificate Filed District Number Register Number
City, TWO;r Schenectady 4601 74
❑Bu al Date Cemetery or Crematory
i01tombment
/22/2013 Pineview Crematory
Address
remation Queensbury, N Y
Date Place Removed
2 Removal and/or Held
❑and/or Address
i= Hold
f
0 Date Point of
Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address •
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave.. Corinth, N.Y. lit;
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
Address
ILI Ce
Permission is hereby granted to dispose of the human remains d`, crib lybov s in i ed.
i i , �_,L,
Date Issued 01/22/2013 Registrar of Vital Statistics 1 lit (, ,
(signature)
District Number Place
4601 Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition I—, 5/,3 Place of Disposition P/AtAr._ + /fir 0), . ,213 ,)&0
a / (address)
(11
CC (section) t nu ber) / (grave number)
2Name of Sexton Pers a of Premises j9f ulkh+61
(please print
Signature 67 d Title ie .-- S
(over)
DOH-1555 (02/2004)