Davis, Susan Arlene 4- tie
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Susan Arlene Davis Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/11/2022 67 Years War or Dates
Place of Death Hospital,Institution or
1/1
Z City,Town or Village Fort Edward Village Street Address 22 Lydius Street, Fort Edward Village,New York 12828
Q Manner of Death ❑Natural Cause Accident Homicide Suicide Undetermined Pending
W C.) Circumstances Investigation
Ui Medical Certifier Name Title
Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 50
Burial Date Cemetery,Crematory or Facility Name
® 06/15/2022 Pine View Crematory
Entombment Address
ZCremation Queensbury Town,New York
Donation
ElRemoval Date Place Removed
H and/or and/or Held
y Hold Address
0
O. Date Point of
CO Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/14/2022 Registrar of Vital Statistics Aimee L Mahoney(Electronically Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F—
Z Date of Disposition (Ind(n ��t Place of Disposition V�.
ddress/
w
N
Q (section) (lot number/ (grave number)
aName of Sexton or Person in Charge f Premises
(pte print)
uJ Signature Title
Ca�r►WmJ�
DOH-1555(o7/18)p t of 2
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#