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Barnes, Suzanne F LCDF ) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records 'T Name First Middle Last Sex Suzanne F Barnes Female Date of Death Age If Veteran of U.S.Armed Forces, 07/07/2023 79 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village South Glens Falls Village Street Address 129 Saratoga Avenue,South Glens Falls Village,New York 12803 ILJ p Manner of Death El Natural Cause Accident Homicide ESuicide nUndetermined Pending W Circumstances Investigation lu Medical Certifier Name Title 0 Shannon Evellis PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Village Of South Glens Falls District Number Register Number City,Town or Village 4524 13 Burial Date Cemetery,Crematory or Facility Name ...1 07/10/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation Z ❑Removal Date Place Removed - and/or and/or Held ~- Hold Address N 0 Date Point of U)ElTransportation Shipment S by Common Carrier Destination IDDisinterment Date Cemetery Address ID Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/10/2023 Registrar of Vital Statistics Samantha Berg(ECectronicaffy Signed) (signature) District Number 4524 Place Village Of South Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 7110 Z3 Place of Disposition `i•.,�1 uJ (address) W N (section) 7/(lot number) (grave number) 0 Name of SextonPerson in Charge of Pre ' 4~ C t li ' Z or (p se print) ILI Title r ni�7Gl Signat�sre DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on buriatpermit Official Funeral Directors Reg.or License#