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Smoczynski, Anne K NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Anne Kathleen Smoczynski Female Date of Death Age If Veteran of U.S.Armed Forces, 08/23/2022 75 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing `p Manner of Death ❑X Natural Cause Accident El Homicide OSuicide Undetermined ri Pending Circumstances Investigation WMedical Certifier Name Title 0 Jennifer Donovan DO Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 122 ©Burial Date Cemetery,Crematory or Facility Name 08/29/2022 Pine View Cemetery Entombment Address Cremation Queensbury Town,New York Donation z❑Removal Date Place Removed and/or and/or Held E= Hold Address 0 EL Date Point of (I)❑Transportation p by Common Shipment Carrier Destination ODisinterment 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 Remains are Shipped,If Other than Above 5 Address Ui a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/24/2022 Registrar of Vital Statistics Caroline Jfi(fegarde Barber(ECectronicallySigned) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: afib4 , 1 f Date of Disposition �'�� a'1 Place of Disposition q�� ����•�� ��-���`j_ �-1J1 N 2 (address) W GRi e LDS Ecc (section) (Tot number) (grave number) 0 Name of Sexton or Person in Charge of Premises Z (please print) w Signature ALA.;A. 4)4. Title Sc,peR i n-�enc,ieni DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) U 1 9935 Receipt Human remain5_mf delivered o , 207 . v --- y ,.: Pine View Cemetery i Representing the funeral home named on burial p rmit Official Funeral Directors Reg.or License# SMOCZYNSKI NAME Anne K Smoczynski Age: 85 Lot Owner: Karl Smoczynski Lot# Erie 68 E Grave# 2 Case: Concrete Died: 8,2 3.2 2 Interred: 8,2 9.2 2 Funeral Home: Baker FH Cemetery: Pine View SMOCZYNSKI Owner Karl Smoczynski Address Plot 21 Lynnfield Dr. Oueensh„ry, NY 12804 Erie Phone # Lot # 518-232-0909 68E Deed # Date 4334 8. 17.22 Cost Foundation Y - N $2100.00 Location West-Lockhart/Soudder East-Vacant North-Belle South-Sheehan Remarks I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE PINE VIEW CEMETERY: SIGNATURE: DATE: eV/ 2/2 SIGNATURE: DATE: Record of Interments 1 6 2 to 8• ass. a� 7 Anne. Srr►ocZ.UpSV.; gacl•as 3 8 4 9 5 10 _._ .L.t r. 41111 • E*c. - 6-18- '191-A1 Zaa.° q 17- 6 q9-q67 1 3