Saudo, Rebecca Smith 21Z
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Rebecca Smith Saudo Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/26/2021 55 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Bolton Town Street Address 36 Skyline Drive,Bolton Town,New York 12814
W Manner of Death Natural Cause El Accident Homicide 0 Suicide ❑Undetermined El Pending
Circumstances Investigation
WMedical Certifier Name Title
a Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Bolton Landing 5650 2
❑Burial Date Cemetery,Crematory or Facility Name
03/03/2021 Pine View Crematory
0 Entombment Address
O Cremation Queensbury,New York
❑Donation
0 ElRemoval Date Place Removed
and/or and/or Held
CO
Hold Address
co Li Transportation Date Point of
p by Common Shipment
Carrier Destination
❑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 Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
2 Address
CC
W
ra Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/03/2021 Registrar of Vital Statistics Jodi LConnall:ygectronicallysigned)
(signature)
District Number 5650 Place Bolton Landing, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition ?-6 -— ( Place of Disposition
2 laddreFiLl
W
MC W
(section) j (lot number) a (grave number)
(,
g Name of Sexton or Person in Cha of Premises /�Ia 7 G' ) E i2ex'C '
Z (please print)
W
Signature * I Title C 7,y ,r
DOH-1555(07/18)p 1 of 2
01.4608
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#