Moore, Susan Ruth NEW YORK STATE DEPARTMENT OF HEALTH el) it
11'113
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Susan Ruth Moore Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/26/2022 72 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Lake George Village Street Address 85 Mohican Street Apt.19,Lake George Village,New York 12845
W Manner of Death Undetermined Pending
G Natural Cause Accident Homicide Suicide
W Circumstances Investigation
W Medical Certifier Name Title
G Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Village Of Lake George District Number Register Number
City,Town or Village 5620 2
HBurial Date Cemetery,Crematory or Facility Name
05/31/2022 Pine View Crematory
Entombment Address
ZCremation Queensbury Town,New York
DDonation
Q❑Removal Date Place Removed
- and/or and/or Held
N
- Hold Address
0
Date Point of
(/)❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
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
H Remains are Shipped,If Other than Above
2 Address
Cr
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/31/2022 Registrar of Vital Statistics Debra Mc(inney(E(ectronicalTySigned)
(signature)
District Number 5620 Place Village Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— l f
W Date of Disposition V I( l Place of Disposition `t '► .iL Zit"--
(address)
W
NCC (sedion) Wt number) (grave number)
k rqt, .., "Wit
G Name of Sexton or Person in Charge of Pre ' s Z (please pt)
r _1
W Signature Title
DOH-1555(o7/18)p 1 of 2
O15 7 F
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ' • " delivered on _ , 20 9
/w
Pine View Cemetery Representing the,Yuneral home named on burial permit
Official Funeral Directors Reg.or License# G '^