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Smith, Denise M. . . #'4)4 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records ' Name First Middle Last Sex ' Denise M.Smith Female ' Date of Death Age If Veteran of U.S.Armed Forces, i'= 02/09/2021 61 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 4H Baybrook Drive,Queensbury Town,New York 12804 ILJ p Manner of Death ©Natural Cause El Accident Ei Homicide ElSuicide ❑Undetermined El Pending Circumstances Investigation W Medical Certifier Name Title CI Michael Adams MD Address 1448 Route 9,Fort Edward Town,New York 12828 ?,= Death Certificate Filed District Number Register Number Dri City,Town or Village Queensbury 5657 44 ❑Burial Date Cemetery,Crematory or Facility Name 02/10/2021 Pine View Crematory Entombment Address Cremation Queensbury Town,New York ,❑Donation 42 Date Place Removed 0❑Removal and/or Held H and/or N▪ Hold Address 0 Ce Date Point of (I) 1-1 Transportation Shipment Q by Common Carrier Destination j a Disinterment Date Cemetery Address �` �Reinterment Date Cemetery Address _,' Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address ▪ 3809 Main St,Warrensburg,New York 12885 'r Name of Funeral Firm Making Disposition or to Whom 4' Remains are Shipped,If Other than Above g Address CC a Permission is hereby granted to dispose of the human remains described above as indicated. ▪ Date Issued 02/10/2021 Registrar of Vital Statistics Caroline xffegarie Bar6er(ECectronicalTy Signed) (signature) District Number 5657 Place Queensbury, New York -, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z lL Date of Disposition ?i RI ?I Place of Disposition 01 e%t<— 2 (address) W N (section) ()lumber) (grave number) CC 1 Name of Sexton or Person in Charge of Premises hr1,` `' �-.4A"1t Z (please pri l W Signature 7.3 t Title Iw TUIti DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) I`'' Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit �. Official Funeral Directors Reg.or License#