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Dane, Susan Louise v,,z. NEW YORK STATE DEPARTMENT OF H EALTH BUrlal' Transit Permit Bureau of Vital Records Name First Middle Last Sex Susan Louise Dane Female Date of Death Age If Veteran of U.S.Armed Forces, 07/25/2023 59 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address Glens Falls Hospital tp Manner of Death Ej Natural Cause Accident Homicide Suicide Undetermined Pending VI—I Circumstances Investigation GMedical Certifier Name Title Gamal Khalifa MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 355 Burial Date Cemetery,Crematory or Facility Name 07/27/2023 Pine View Crematory IllEntombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held Hold Address CO 0 d Date Point of (f) Transportation p by Common Shipment Carrier Destination O Disinterment Date Cemetery Address ElReinterment 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 .- Remains are Shipped,If Other than Above E. Address lz W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/26/2023 Registrar of Vital Statistics Megan Nolin(Electronically Signed) (signature) District Number 5601 Place City Of Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 LU Date of Disposition 7--Zetpr? Place of Disposition j ,�� vS e;,d (address) W Ce N (section) (lot number) (grave number) SName of Sexton or Person in Charge of emis s Rid/mv"./, k1aev4 Z (please print) LU Signature Title Oe t os DOH-1555(o7/i8)p t of 2 ) I 7 I '•3I, Public Health Law Sec. 4145(2b) Receipt Human remains of _ delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#