Casey, Susan Alexis Hull NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Susan Alexis Hull Casey Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/24/2022 77 Years War or Dates
F. Place of Death lttital,Institution or
Z City,Town or Village Queensbury Town Street Address 1260 West Mountain Road 211,Queensbury Town,New York 12804
Manner of Death ❑ ❑ ❑Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Lynn Keil PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 104
Burial Date Cemetery,Crematory or Facility Name
06/27/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
~
N Hold Address
0
O. Date Point of
N Transportation
CI by Common Shipment
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
F.. Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/27/2022 Registrar of Vital Statistics Carolinexltlegardf Bar6er(ECectronicallySigned)
(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:
Z
Z Date of Disposition wig(ZL Place of Disposition _
2 (address)
W
CC CC (section) (lot number) c (grave number)
8 Name of Sexton or Person in Charge o Premises pint/ILI a, ,,,
Signature Title
DOH-1555 07/18)p t of 2
1 Public Health Law Sec. 4145(2b) f
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral-Mine named on burial permit
Official Funeral Directors Reg.or License#