Smith, Diane NEW YORK STATE DEPARTMENT OF HEALTH , . Z f L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Diane Sue Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 12, 2017 Age,
War or Dates
El Plac ath Hospital, Institution or
zf-
Ci ow or Village Argyle Street Address Washington Center
1 Ma of Death 0 Natural Cause ❑ Accident ❑ Homicide ElSuicide ❑ Undetermined ❑ Pending
ILL Circumstances Investigation
W Medical Certifier Name Title
0 Edit Masaba,
Address
E-_°`, 35 Gilbert Street Cambridge, NY 12816
l 4' Deat cate Filed District Number C Register Number
City, T wn Village A-d f 4 1 e • J 7 5 O
0 Burial Date Cemetery or Crematory
March 14, 2017
0 Entombment
Address
!; ®Cremation
Date Place Removed
❑ Removal and/or Held
and/or Address
p Hold
Date Point of
I ❑Transportation Shipment
by Common Destination
Carrier _
❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
.' Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
,.$f Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
;- Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Address
Ce
W:
c Permission is hereby granted to dispose of the human r ins described above as indicated.
Date Issued {fir Registrar of Vital Statistics , P two
(signature)
District Number 5750 Place Nig_
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ELl Date of Disposition 03/ /2017 Place of Disposition '/hei)ire vd G,t �rla- `ni
'21 (address)'
1.
)
It (section) (lot number) (grave number)
s Name of Sexton rs in Charge of Premises -3t"12 G.ri C9G..vdl cz_C-li@-
(please print)
. Signature Title L1G�mr,
(over)
DOH-1555 (02/2004)