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Smith, Luella if i NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Pe mit Name First Middle Last Sex Luella S. Smtih Female Date of Death Age If Veteran of U.S. Armed Forces, October 27, 2018 91 War or Dates Place of Death Hospital, Institution or WCity, Town or Village Greenwich Street Address 835 County Route 52 Ea Manner of Death rn E.J Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending C3 Circumstances Investigation Medical Certifier Name CI Viz- ��� 51� 1 ti p Title Address 35 dtloM5. s' r'tI 6-1. N4 . la$it Death Certificate Filed District Numb r Register Number City, Town or Village Greenwich .5'75`7 1 0 ❑Burial Date Cemetery or Crematory October 29, 2018 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed zRemoval 0 ❑ and/or Held and/or Address p Hold M Date Point of 0 ❑Transportation Shipment Cl) by Common Destination G Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077 Address 123 Main St., Argyle NY 12809 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above gAddress W 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued tDf 261hV Registrar of Vital Statistics (signature) District Number 5'75') Place 4.1>1 12 w 3 y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w' Date of Disposition 10/29/2018 Place of Disposition Quaker Road Queensbury,NY 12804 2' (address) W Co Et (section) "rot number) (grave number) Q Name of Sexton or Person in Charge of Premises L 4t it+��It Z / (pid ase print) Ili Signature 4 ✓4p Title MOWN— (over) DOH-1555 (02/2004)