Howe, Susan Jane Iffo 4 -7St
NEW YORKSTATE DEPARTMENT OFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Susan Jane Howe Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/24/2022 80 Years War or Dates 1962-1963
Place of Death Hospital Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death a Natural Cause Accident 0 Homicide OSuicide Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
Cit ,Town or Village 5601 499
Burial Date Cemetery,Crematory or Facility Namery
Addre2022 Pine View Cremato
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
N Hold Address
0
0. Date Poi rut of
CO❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Re interment
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
I— Remains are Shipped,If Otherthan Above
5 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/29/2022 Registrar of Vital Statistics Afegati_wa n(E4ctrtm SOttea)
(signature)
District Number 5601 Place City Of Glens Fags
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �(
Date of Disposition e_/20 z 3lace of Disposition I), >J e l/ e,..) (7r`f'i/1'I Gi s "c
W (address)
W
M (motion) (lot'wither) (gm a.number)
gName of Sexton or Person in Charge of Premises K197/"l b,1 '> 1 0PC4
Z '_ ' I(please� se print)
W Signature /.��'�i i / Title P;-'t,T�i
DOH t555(07/18)pi of 2
1
1 ;14 a
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#-