Simmons, Susan Vickers T # 701
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Susan Vickers Simmons Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/05/2022 70 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p• Manner of Death El Natural Cause Accident El Homicide Suicide ❑Undetermined ❑Pending
✓ Circumstances Investigation
W Medical Certifier Name Title
O Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 22
Burial Date Cemetery,Crematory or Facility Name 03/07/2022 Pine ViewCrematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
❑Removal Date Place Removed
and/or and/or Held
pN Hold Address
0
d Date Point of
(I)DTransportation
a by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
ElReinterment 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
H Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03107/2022 Registrar of Vital Statistics Aimee..ladwrrcy(Th oilicalTy S0e4
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ��
~ .(.�N--
Z Date of Disposition � �2� Place of Disposition F141
W s)
2
W
N
Cr (section) (lot number) c� (grave number)
8 Name of Sexton or Person in Charge of Pre ' es f%)*L., �A1iZse print)
t1J -49
Signature Title
`�/.�iM }G
DOH t555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# •�