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Samascott, Patricia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit s Name First Middle Last Sex Patricia A. Samascott Female i Date of Death Age If Veteran of U.S. Armed Forces, 11 / 25 / 2017 77 War or Dates N/A 11. Place of Death Hospital, Institution or f City, Town or Village Milton Street Address 744 Rte #29 0 Manner of Death®Natural Cause 0Accident 0 Homicide E Suicide Undetermined �Pending itiCircumstances Investigation la Medical Certifier Name Title a Hung D. Nguyen MD Address 19 West Ave Ste 101 Saratoga Springs, NY 12866 Death Certificate Filed District Number ' 15b Register Number 5 Li City,Town or Village Milton `-t Burial Date Cemetery or Crematory il / 27 / 2017 Pine View Crematory DEntombment Address '?ECremation Queensbury, NY Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of tiQ Transportation Shipment Ls by Common Destination in Carrier Q Disinterment Date Cemetery Address iM Oi: 0 Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Compassionate Funeral Care 00364 Address 402 Maple Ave. , Saratoga Sp. , NY 12866 iliiii gigi Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above a Address CC iti Permission is hereby granted to dispose of the human remadescribed abo 'ndicated. Iiiiiii Date Issued If I a r7 )a,©(7 Registrar of Vital Statistic( L1113 signature) District Number Li + Place Milton , New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 11 /7'i()) Place of Disposition ?,Al- 6'3,09- ► (address) 0 Ili (section) 4(lot number) (grave number) 0. rAi et Name of Sexton or Person in Charge of Pre ises • 5 �� ► (test-'print) - 44 Signature "'` pr Title l'I''V ft Tg- (over) DOH-1555 (02/2004)