Mondor, Susan Marie NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Susan Marie Mondor Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/29/2023 79 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
111 Manner of Death Natural Cause Accident []Homicide Suicide []Undetermined [Pending
f 'Circumstances I 'Investigation
WMedical Certifier Name Title
CI Romel Gobunsuy MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 307
Burial Date Cemetery,Crematory or Facility Name
06/01/2023 Pine View Crematory
[]Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
d Date Point of
Cr)[]Transportation Shipment
p by Common
Carrier Destination
[ ]Disinterment
Date Cemetery Address
111
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
l- Remains are Shipped,If Other than Above
2 Address
CC
W
is Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/31/2023 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition $/3i '7,3 Place of Disposition . �V,
2 (address)
W
CC
to (section) number) (grave number)
4 (lot
r .
8 Name of Sexton or Person in Char Premises
(pe print)
W Signature Title �� ��
DOH-1555(07/18)p t of 2
P
t--1
1 I
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#