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Smith-Allen, Sara Daisy NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Sara Daisy Smith-Allen --TFemale Date of Death Age If Veteran of U.S.Armed Forces, 11/20/2019 73 Years War or Dates ZPlace of Death Hospital,Institution or W City,Town or Vlllage Queensbury Town Street Address 125 Robert Gardens North 1,Queensbury Town,New York 12804 pManner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetennined ❑Pending Circumstances Investigation Medical Certifier Name Title Michael Adams MD Address 1448 Route 9, Fort Edward Town,New York 12828 Death Certificate Filed District Number FRegister Number City,Town or Village Queensbury 5657 ❑Burial Date Cemetery,Crematory or Facility Name ❑ 11/21/2019 Pine View Crematory Entombment Address FRICremation Queensbury Town, New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held ~ Hold Address O (L Date Point of U) ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Horne-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition orto Whom }— Remains are Shipped,If Other than Above Address W CI Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/21/2019 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition /'�)1Z,1lq Place of Disposition �, �— (address) W cc (section) /1 (/ot nu er/ (grave number) Name of Sexton or Person in Charge of Premises Z /ease print/ Signature % Title t' 1A DO H-t555(07/18)p 1 of 2 Public Health Law Sec. 4145�2b� ., Receipt Human remains of delivered on �� , 20' View Cemetery Representing the funeral home named on burial permit -Official Funeral Directors Reg.or License# �'