Thompson, Susan 330
NEW YORK STATE DEPARTMENT OF HEALTH 6":".F)
Bureau of Vital Records Burial -Transit Permit
Name First Middle Last Sex
Susan Thompson Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/18/2022 70 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 17 Seward Street,Queensbury Town,New York 12804
G Manner of Death II Natural Cause Accident Ei Homicide OSuicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town of Queensbury District Number Register Number
Cit ,Town or Village 5657 76
Burial Date Cemetery,Crematory or Facility Name
04/20/2022 Pine View Crematory
Entombment Address
Elremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
F17) Hold Address
0
a Date Point of
IA Dfransportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
pReinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
2 Address
Q
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/19/2022 Registrar of Vital Statistics Cam!'ins.7in gar4Barivr(E4ctronicah Sigrrr0
(signature/
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 4"I I ZZI2Z Place of Disposition h,t� /
a (address)
W
N CC (section) (lot number/)
(grave number)
/� It
� Name of Sexton or Person in Charge of Premises rt> J'gnl
_
z /�� /l�IesePrint/
W Signature c✓( Title (WO ItiVe
DOH 1555(07/18)p i of 2
0,15986
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#