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Smith, Betty Jane 01,6 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Betty Jane Smith Female Date of Death Age If Veteran of U.S.Armed Forces, 12/23/2021 91 Years War or Dates IH Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc W Manner of Death Undetermined W ©Natural Cause Accident Homicide 0 Suicide ElUd id ElPdi g Circumstances Investigation WMedical Certifier Name Title 0 Eric Santell NP Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 72 ❑Burial Date Cemetery,Crematory or Facility Name 12/28/2021 Pine View Crematorium Entombment Address 0 Cremation Queensbury Town,New York ❑Donation ZO Removal Date Place Removed and/or and/or Held Hold Address N 0 O. Date Point of (I) 1-1 Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O. Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1- Remains are Shipped,If Other than Above 5 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/28/2021 Registrar of Vital Statistics Aimee L Mahoney(Efectronicaffy Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1- Z Date of Disposition b_-?-r)1 Place of Disposition Dt't c V�.,V <f� c4cr y� U (address) W CC (section) (lot number) (grave number) 0 Name of Sexton or Person in Char f Premises 3—Ur,�Y' 4/,ri (please print/ W Signature Title C.r2,ric%ec( DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on 20 .. f f a" Pine View Cemetery Representing the funeral home named on burialpermit Official Funeral Directors Reg.or License#