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Smith, Melinda 9 NEW YORK STATE DEPARTMENT OF HEALTFIO .. `� �O Vital Records Section Burial - Transit Permit Name First Middle Last Sex Melinda ig., Smith Female Date of Death Age If Veteran of U.S. Armed Forces, February 25, 2013 52 War or Dates t Place of Death Hospital, Institution or Z; City, Town or Village Queensbury, NY Street Address 145 Farr Lane Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation i Medical Certifiiert Name Title Address t3�\\sue S n aQ_i Death Certificate Filed 1 District Number Register Number City, Town or Village Queensbury,NY 5657 ❑Burial Date Cemetery or Crematory February 27, 2013 Pine View Crematory ❑Entombment Address 0 Cremation Quaker Road, Queensbury,NY 12804 Date Place Removed Z Removal and/or Held O —and/or Address E Hold U) O Date Point of Nn Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Road, Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom I-: Remains are Shipped, If Other than Above Address w Permission is hereby granted to dispose of the human r ins described abo'(etas indicated. Ct ,C Date Issued �-1?,(©��,IRegistrar of Vital Statistics C� �.,- . 8(L,�� (signature) District Number 5657 Place Queensbury,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 2.-71- Place of Disposition �.0 kpj C�.r,� �,hoe- 2 (address) W co O (section) Ao t (lot number) (grave number) Op Name of Sexton or Person in Charge f Premises nr4 W (please print) Signature4._ Title G nyrid (over) DOH-1555(02/2004)