Feeley, Susan Carol 7o)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Susan Carol Feeley Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/21/2021 7,0 Years War or Dates
Place of Death Hospital,Institution or
W
• City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death ❑X Natural Cause Accident 1=1Homicide El SuicideUndetermined Pending
LU
0 Circumstances Investigation
W Medical Certifier Name Title
O Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 358
❑Burial Date Cemetery,Crematory or Facility Name
08/24/2021 Pine View Crematory
ElEntombment Address
gCremation Queensbury Town,New York
Donation
o• ElRemoval Date Place Removed
and/or and/or Held
H N Hold Address
0
d Date Point of
N ❑Transportation
0 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
Address
CC
ill
▪ Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/24/2021 Registrar of Vital Statistics RodertyInefrew Curtis(EI ctranicaLySrgned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 2 1—')-1 Place of Disposition pyf'N p, y; / �¢,mktior)'
W
2 (address)
W
CC CC (section) ''j� (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises v Zr �y " '�
0 (please print)
� � /�
W
Signature �..�
Title C./v►» r
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of . # delivered on , 20
amine View Cemetery Representing the funeral homrmed;on burial permit
Official Funeral Directors Reg.or License#