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Smith, Doris Jean NEWYORK STATE DEPARTMENT OF HEALTH q • Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Doris Jean Smith Female Date of Death Age If Veteran of U.S.Armed Forces, 01/04/2020 82 Years War or Dates ZPlace of Death Hospital,Institution or W City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc a Manner of Death ©Natural Cause ❑Accident �Homicide �Suicide �Undetermined 0 Pending U Circumstances Investigation QW Medical Certifier Name Title John Quaresima MD Address _ 319 Broadway, Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 2 ❑Burial Date Cemetery,Crematory or Facility Name 01/10/2020 Pine View Crematory Entombment Address FRI Cremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held ~ Hold Address 0 (L Date Point of U) Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom i-. Remains are Shipped,If Other than Above Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/06/2020 Registrar of Vital Statistics Aimee 91,1akoney(ECectronically Signed) (signature/ District Number 5755 Place Fort Edward, 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 ' Ip 76 Place of Disposition �/ 2 /address/ W NIX (section) (lotnumber) (grave number) Name of Sexton or Person in Charge o�remises k� Z (p ase print/ W Signature ZTitle C DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013223 Receipt Human remains of r : .- r .r�= " - delivered on ,,:" ' , 20 Pine View Cemetery Representing the juneral home named on burial permit Official Funeral Directors Reg.or License#