Smith, Danielle A di 'Ls
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Danielle A.Smith Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/12/2021 44 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 25 Edgewood Drive,Queensbury Town, New York 12804
UJ
p▪ Manner of Death ❑X Natural Cause Accident ❑Homicide Suicide El UndeterminedPending
✓ Circumstances Investigation
LU Medical Certifier Name Title
0 Andrea Breen NP
Address
43 New Scotland Avenue MC7,Albany,New York 12203
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 223
❑Burial Date Cemetery,Crematory or Facility Name
11/16/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
o ElRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
co 11 Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/15/2021 Registrar of Vital Statistics Carolinex�gard Bar6er(!Yectronicaff 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 Date of Disposition ji/1/I Zi Place of Disposition
2 (address)
W
CC
t/)
(section) itt number) (grave number)
• Name of Sexton or Person in Charge of Premises (.) L�
Z (please pt/
W Signature Title 11illi !► �" „
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 1` 5
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burialcp?rmit
Official Funeral Directors Reg.or License#