Smith, Joanne Marie i
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Per it
Bureau of Vital Records
Name First Middle Last Sex
Joanne Marie Smith Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/12/2022 89 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Ip Manner of Death ❑X Natural Cause ❑Accident El Homicide ElSuicide ❑Undetermined 1=1 Pending
V Circumstances Investigation
MI Medical Certifier Name Title
G Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 6
O Burial Date Cemetery,Crematory or Facility Name
01/13/2022 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
RemovalEl
Date Place Removed
and/or and/or Held
N Hold Address
0
O. 1-1
Date Point of
co Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
a Address
CC
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/13/2022 Registrar of Vital Statistics Aimee ctronicaf SigneQJ
(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:
I—
Z Date of Disposition f/15-121 Place of Disposition 47n dl.... „i-r.)---
W (address)
W
CC N (section) J/ ltot number) (grave number)
GName of Sexton or Person in Charge of Pr mises �"
f n/pie e print/ n,�
W Signature (// Title l'�"
DOH-1555(07/18)p t of 2
_____
1
J .} �. ,
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#