Smock, Janice S. # go
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Janice S.Smock Female
i Date of Death Age If Veteran of U.S.Armed Forces,
12/02/2019 71 Years War or Dates
18 Place of Death Hospital,Institution or
City,Town or Village Queensbury Town Street Address 1260 W Mountain Road 216,Queensbury Town,New York 12804
WManner of Death ®Natural Cause Accident Homicide Suicide Undetermined Pending
1 Circumstances Investigation
QMedical Certifier Name Title
Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 180
Burial Date Cemetery,Crematory or Facility Name
El12/09/2019 Pine View Crematory
Entombment Address
LLJ
Cremation Queensbury Town,New York
Donation
Z Date Place Removed
0 Removal P and/or and/or Held
N Hold Address
O
a Date Point of
N ❑Transportation
p by Common Shipment
Carrier Destination
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/04/2019 Registrar of Vital Statistics CaroCne 9CiflCegarde Bar6er(ECectronicallySigned)
(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:
F
Z Date of Disposition Place of Disposition
W
(address)
W
(section) of number) (grave number)
aName of Sexton or Person in Charge of Premises AV -�-• >`+f
Z (p/e a print
UJI
Signature Title �6MA I
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) - 0-1J 1_3
Receipt
Human remains of ' , �;b�� , !-F delivered on , 20
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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