Sutphen, Elizabeth Jean Marie (111) . ,s,p
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Elizabeth Jean Marie Sutphen Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/05/2022 93 Years War or Dates
�.. Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p Manner of Death El Natural Cause Accident ❑Homicide DSuicide nUndetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 _ 250
Burial Date Cemetery,Crematory or Facility Name
05/09/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
~ Hold Address
0
O. Date Point of
Cl)❑Transportation Shipment
Q by Common
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
-. Remains are Shipped,If Other than Above
Address
Q
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/06/2022 Registrar of Vital Statistics Megan Wolin(ECectronicalrySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition S=7 2O2Z Place of Disposition 9,` Ale (, t reyf
(address)
W
N CC (section) (lot number) (grave number)
a
0 Name of Sexton or Person in Charge o remiss '/f" �FJ� 11)6 0
Z //p ease print)
W Signature Title
DOH-1555(o7/18)p t of 2
L... . _.., `rs; ".. %
Public Health Law Sec. 4145(2b)
Receipt
Human remains of t delivered on , 20
Pine View Cemetery Representing the funeral home named opr burial permit
Official Funeral Directors Reg.or License# '