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NEWYORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Hazel M Suckman Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/16/2022 75 Years War or Dates
F_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death nUndetermined Pending
W Ei Natural Cause Accident Homicide Suicide I
Circumstances Investigation
WMedical Certifier Name Title
C Eileen Spinelli NP
Address
Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 269
Burial Date Cemetery,Crematory or Facility Name
i 05/18/2022 Pine View Crematory
Entombment— Address
IIICremation Queensbury Town,New York
Donation
IS❑Removal Date Place Removed
and/or and/or Held
f- Hold Address
N
0
d. Date Point of
Cl)0Transportation
CI Common Shipment
Carrier Destination
o
Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
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
H. Remains are Shipped,If Other than Above
2 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/18/2022 Registrar of Vital Statistics %tegan NoCn(ECectronica1Cy Signed)
(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 s1 i11lj Place of Disposition rtt�
IH
(address)
W
to
Q (section) i���(lot n umbe (grave number)
Z0 Name of Sexton or Person in Charge of r mises
// ase pri
uJ Signature Title it Pk
DOH-1555(07/18)p 1 of 2
1 ‘
m 0 i . A
Public Health Law Sec. 4145(2b)
Receipt
iHuman remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#