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Bautista,Susan Marie NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records �_� Name First Middle Last Sex Susan Marie Bautista Female Date of Death Age If Veteran of U.S.Armed Forces, 10/24/2023 66 Years War or Dates i— Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 13 Linette Lane,Queensbury Town,New York 12804 p Manner of Death 111 Natural Cause Accident Homicide 0 Suicide Undetermined r7 Pending IL' V Circumstances Investigation ILI G Medical Certifier Name Title Aqeel Gillani MD Address . 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village , 5657 161 Burial Date Cemetery,Crematory or Facility Name 10/25/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation ZO o Removal Date Place Removed H and/or and/or Held N Hold Address 0 O. Date Point of (/) Transportation p by Common Shipment Carrier Destination ODisinterment Date Cemetery Address ElReinterment Date Cemetery Address 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 1— Remains are Shipped,If Other than Above 2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/25/2023 Registrar of Vital Statistics Caroline fdegardfe Barber(ElectronicafTy Signed) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition /t-ZI Zii3 Place of Disposition 7 Aie V. e(,�) C r .,-j 4,. -� 2 (address) W Cl) (section) (lot number)Cl (grave number) SName of Sexton or Person in Charge Premises ' Pt'FJ W,� L J©t> W ` (please print) Signature �, /I Title el 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 burial.permit Official Funeral Directors Reg.or License#