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Smith, Colette NEW YORK STATE DEPARTMENT OF HEATH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Colette Marie Smith Female Date of Death Age If Veteran of U.S.Armed Forces, December 22, 2017 75 War or Dates I Place of Death Hospital, Institution or LuZ City, Town or Village Kingsbury Street Address 128 Feeder Street WManner of Death a Natural Cause Accident Ej Homicide El Suicide n Undetermined ri Pending U Circumstances Investigation W° Medical Certifier Name Title W Thomas Coppens, M.D. Dr. Address Three Irongate Center Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village 3 7 6 --) J ❑Burial Date Cemetery or Crematory December 27, 2017 Pine View Crematorium El Entombment Address , ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z111 Removal and/or Held and/or Address Hold CO Date Point of IIEl Transportation Shipment t1) by Common Destination a Carrier Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address 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 2 Address WI',' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued /,4) (,//7 Registrar of Vital Statistics . r thu v , (signature) District Number 5 7( ) Place %i Lv r 6 / A As S-6 wy J --` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 12/27/2017 Place of Disposition Quaker Road Queensbury,NY 12804 W (address) CO W (section) / (lot number) (grave number) C I Name of Sexton or Person in7arge of Pre es /�.,, , 5-,.�(ti ( ease print) Signature I" Si -_--. i -+1"' Title alifilt R a (over) DOH-1555 (02/2004)