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Smith, Laurie NEW YORK STATE DEPARTMENT OF HEALTH # LL 1 Vital Records Section Burial - Transit Permit a ffi Name First - Middle Last Sex Laurie C. Smith Female . Date of Death Age if Veteran of U.S. Armed Forces, <a 1 2/1 5/201 2 77 yrs. War or Dates No Place of Death Town of Hospital, Institution or Z City, Town-or Village Hague Street Address 16 Overbrook Road @©. Manner of Death E Natural Cause 0 Accident E Homicide 0 Suicide Ei Undetermined Ei Pending Circumstances Investigation Medical Certifier Name Title 9. Richard McKeever M.D. Address »> ' 102 Racetrack Road, -Ticonderoga, New York 12883 i:iiii:i:i Death Certificate Filed Town of District Number Register.Number City, Town or Village Hague 5653 Date Cemetery or Crematory ❑Burial 1 2/1 8/2 01 2 Pine View Crematory Address Cremation Queensbury, New York Date Place Removed OC Removal and/or Held and/or Address — Hold 0 Date Point of 05 Q Transportation Shipment 0 by Common Destination Carrier Disinterment Date Cemetery Address • Reinterment Date Cemetery Address . Permit Issued to Registration Number <3 Name of Funeral Home Wilcox & Regan funeral home 01 821 .ip <<: Address 11 Algonkin St. , Ticonderoga, New York 12883 iii Name of Funeral Firm Making Disposition or to Whom ht Remains are Shipped, If Other than Above Address w 4, Permission is hereby granted to dispose of the human remains described above as indicated. 1 Date Issued 1 2/1 8/2 01 2 Registrar of Vital Statistics-- , .1 MC3..�;9- 6. 4 ,n n . ,1 (sig ture) District Number 67053 s Place Town of Hague I certify that the remains of the decedent identified above were disposed of in accordance with this permit on; EDate of Disposition 12-19-0.. -Place of Disposition 1,.6 arJ Ot44Prrv-- 2 (address) W t/a ce (section) /j" jlot numbek ,p (grave number) Name of Sexton or Person in Charge f Premises n?f "►"'�'1 Z (please print) Ui Signature 1A , Title C" v.}- / - DOH-1555 (10/89) p. 1 of 2 VS-61