DePalo, Susan H UP
NEW YORK STATE DEPARTMENT OF HEALTH - Burial - Transit Permit
Bureau of Vital Records
wunierip
Name First Middle Last Sex
Susan H.DePalo Female
Date of Death Age If Vete;an of U.S.Armed Forces,
07/30/2022 76 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
QMariner of Death ^ I I Natural Cause []Accident []Homicide []Suicide Undetermined []Pending
U f ' Circumstances I 'Investigation
WC1 Medical Certifier Name Title
Scott Biasett MD
Address
100 Park St,Glens Falls, New York 1280 I
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 398
Burial Date Cemetery,Crematory or Facility Name
08/01/2022 Pine View Crematorium
[]Entombment Address
[]Cremation Queensbury Town, Nevt York
aDonation
01 ]Removal Date Place Removed
and/or and/or Held
- Hold Address
0
Date Point of
(n[]Transportation
CI Common Shipment
Carrier Destination
[]Disinterment Date Cemetery Address
C Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address —68 Main Street,P.O.Box 67,Hudson Fa Is. New York 12839
Name of Funeral Firm Making Disposition t Whom
�—. Remains are Shipped,If Other than Above
2 Address
CC
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/01/2022 Regis.•ar of Vital Statistics Megan]1ofin(EfectronicaffySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent item ified above were disposed of in accordance with this permit on:
W Date of Disposition gig I lZ Place of Disposition 414. 1
(address)
w
CC
(section) (lot number) (grave number/
it
0 Name of Sexton or Person in Charge of Prerui1 to
Z ( ease print)
W Signature Title +w7e
DOH-1555(o7J18)p 1 of 2 v�
Public Health Law Sec. 4145(2b)
Receipt
1 Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#