Ringer, Susan J 01/04/2022 TUE 10: 44 FAX * �� 0oo1/001
01/04/2022 11;10 AM FAX 6187461689 - eton Funeral Some i� [ J0001/0001
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First Middle ' z Last Sex
Susan J. Rinc er I
Female
Date of Death Age ran of U.S.Armed Forces,
`('`' December 28,2021 72 .� War or Dates
Place of Death 'Hospital; Institution or _
City, Town or Village Glens Falls Street Address Glens Falls Hospital
' Manner of Death 0 Natural Cause Ej Accident ❑ Homicide I I Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
XARA COAM11,5 PA
• Address
• ./oa PA RIG s-r, G Iaus,. N'Y
. Death Certificate Filed District Number Register Number
.., , Town or Village GiF S 1.3 5C I y
0 Burial Date Cemetery or Crematory
January 4, 2022 Pine View Crematorium
.. 0 Entombment Address
i Cremation Quaker Road Queensbury,NY 12804
Date _ Place Removed
2, Fi Removal _ and/or Held
and/or Address
.?- Hold
Q n
:EL Date Point of -
I J Transportation I Shipment
by Common Destination •
;5, Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number ,
• Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address _.. ..- - .. .
• Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
r e of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
t Address
ia. Permission Is hereby granted to dispose of the human remains described above as indicated.
- Date Issued I t4)2a2.2 Registrar of Vital Statistics rCo2)42
(mature)
. District Number 56,0 I Place 6615 IllS, NY .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
a Date of Disposition 01/04/2022 Place of Disposition Quaker Road Queensbury,NY 12804
-
M. (address)
;a:
Lt, (section) A (lot number) (grave number)
el Name of Sexton or Person i7eofP7 S h r4.4�. .�mµ(�
Z- (pse print) �^
Ul: Signature .. . Title ` gCniliT0e
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1 ... ,
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#