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Smith, Mary Ata 1� o # )1 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Mary Ata Smith Female Date of Death Age If Veteran of U.S.Armed Forces, 01/18/2018 77 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Granville Town Street Address The Orchard Nursing And Rehabilitation Centre Manner of Death ©Natural Cause ❑Accident ❑Homicide ['Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title 3 Jennifer Hayes MD Address 11 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City, Town or Village Granville 5756 2 ❑Burial Date Cemetery or Crematory 01/22/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address � Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address 1a Permission is hereby granted to dispose of the human remains described above as indicated. iDate Issued 01/18/2018 Registrar of Vital Statistics Julia Goff(E(ectronica((ySigned) r„, (signature) i # District Number Place 5756 Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: tU Date of Disposition //23[�t Place of Disposition ek . ,.we (address) (section) lot number) (grave number) j, Name of Sexton or Person in Charge of Premises tLr•t :+-ddf `_. �J *4 (piase print Signature i//,� Title Pkmit- i/- (over) DOH-1555(02/2004)