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Smith, Gertrude Town of Queensbury Certification of Cremation s � Pine View Cemetery and Crematory This certifies that the remains of: Gertrude Smith were cremated on September , 2 20 21 at the Pine View (Month) (Day) Crematorium, Queensbury,New York, and these are the cremated remains of said body. Date of Death August , 27 20 21 Age 100 (Month) (Day) Funeral Home Regan Denny Stafford Registered No. 735 .4_ (Authorized Signature) • r -4 -)3r NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gertrude G Smith Female Date of Death Age If Veteran of U.S.Armed Forces, 08/27/2021 100 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address 23 Alta Avenue,Queensbury Town,New York 12804 pManner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title a Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 181 ❑Burial Date Cemetery,Crematory or Facility Name 09/01/2021 Pine View Crematory ❑Entombment Address ▪Cremation Queensbury Town,New York ❑Donation Z Removal Date Place Removed and/or and/or Held - Hold Address 0 CL 1-1 Date Point of to ❑Transportation Shipment p by Common Carrier Destination Date Cemetery Address ❑Disinterment ❑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 t Remains are Shipped,If Other than Above • Address CC Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/01/2021 Registrar of Vital Statistics Caroline Wildegarde Barber(ECectronicallySigned) (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: Date of Disposition 'j I Z IL, Place of Disposition tq(.`1.—„ C t i'ry (address) W pc (section) (lot number) (grave number) 8 Name of Sexton or Person in Charge of Prey es `Iin 1 �C (p/e�e print/ Signature Title (PS`"RV< DOH-1555(o7/18)p t of 2 • 0 ,•k.. 01 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# Smith NAME Gertrude Smith Age: 100 Lot Owner: Dennis Smith Lot#Free Ground/ New Kenesaw Grave# 24 B Case: Urn Died: 8/2 7/2 0 21 Interred:9/8/2 0 21 Funeral Home: Regan Denny Stafford Cemetery: Pine View SMITH Lot No. Free Groun Address Section No. Owner Dennis Smith Plot New Kenesaw Date Approx. 33 Superficial ft. (� Location Bounded on the North by LaPoint, East by Path West by Duchaine and South by Searles Corner Posts Remarks Interred in grave 24 on FRee GRound located near New Kenesaw Deed No. (and changes) Payment Record Record of Interments LAPomIT 24 Dennis Smith ( 12/18/1995 ) 7./1 24 e.c--k-cucle..Sn:a-NA S 443 l v S P fJ s C A + x T s A FA N < > E v Form No. 01