Glasheen, Susan Gail , ''' (1.<1-5 -°._5--/Z
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Susan Gail Glasheen Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/29/2022 63 Years War or Dates
1_, Place of Death Hospital,Institution or
Z City,Town or Village Grenville Village Street Address Granville Center for Rehabilitation and Nursing
iii
a Manner of Death Ej Natural Cause ❑Accident 0 Homicide Suicide Undetermined Pending
IU
V Circumstances Investigation
N Medical Certifier Name Title
Shardul Kopper DO
Address
17 Madison St,Granville Village,Newyork 12832
Death Certificate Filed Village of Granville District Number Register Number
Cr g 5725 26
Burial Date Cemetery,Crematory or Facility Name
Addre2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
F and/or and/or Held
N Hold Address
0
a Date Point of
N OTransportation
a 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
H Remains are Shipped,If Other than Above
a Address
CC
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/30/2022 Registrar of Vital Statistics WlrarJ4ep6erts(F,leirrv>t> igned)
(signature)
District Number 5725 Place Village Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-
6 Date of Disposition 7-Z-2v7 -Place of Disposition ; � u►P � � ) C re siltf^,,�
2 (adaress)
W
N
CC (section) (lot n mberl (grave number)
8 Name of Sexton or Person in Charge remiss "---- 4►1(r110,,(1 D 6�
Z (please print/
W Signature cr-i.4e 4 Title Gf 4r4.+01—
DOH 1555(o7/18)p t of 2
Art]
Public Health Law Sec. 4145(2b)
Receipt
Human remains of - _ delivered on , 20 - ',
l l ..
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# !`"fi f `