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Smith, Dorothy T i, NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dorothy T Smith Female Date of Death Age If Veteran of U.S.Armed Forces, 12/08/2021 94 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 190 Rockwell Road,Queensbury Town,New York 12804 WW Manner of Death ©Natural Cause 12 Accident El Homicide El Suicide �Undetermined Pending V Circumstances Investigation 0 Medical Certifier Name Title 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 237 ❑Burial Date Cemetery,Crematory or Facility Name 12/10/2021 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York ❑Donation Z Removal❑ Date Place Removed and/or and/or Held H N Hold Address 0 O. Date Point of f/) ❑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 — Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/10/2021 Registrar of Vital Statistics Caroline rfildegarde Barber(ECectronica1ty 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 /L//Z(JZ/ Place of Disposition Ak3 (,ree—t) C,'e-.'i t. ,cC� (address) --� W CC CC (section) (lot number) (grave number) 8 Name of Sexton or Person in Charg Premise i a0^-/ 1,6ri-i) Z -(please print) W Signature �e Title QeQ es-Ar U f DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1 "" 5 1_ Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#