Smith, Christine Elizabeth g 1'JEW YORKSTATE DEPARTMENT OF HEALTH (\LL
Burial - Transit Permit
3ureau of Vital Records
Name First Middle Last Sex
Christine Elizabeth Smith Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/28/2022 77 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
UJ Manner of Death g
!"] �NaturalCause Accident Homicide Suicide Undetermined (�Pendin
UJ Circumstances ''Investigation
(,)
Ili Medical Certifier Name Title
Joshua Starteri NP
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed Town Of Granville District Number Register Number
City,Town or Village 5756 62
Burial Date Cemetery,Crematory or Facility Name
11/01/2022 Pine View Crematorium
Entombment Address
[]Cremation Queensbury Town,New York
Donation
ID• ❑Removal Date Place Removed
and/or and/oi Held
F�-i? Hold Address
•
t'
l 1. Date Point of
Transportation
.] 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 Yoh(12839
Name of Funeral Firm Making Disposition or to Whom
I"_ Remains are Shipped,If Other than Above
iE Address
OC
UJ
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/01/2022 Registrar of Vital Statistics jenny Linda M MarteCCe(ECectronica1CySigned)
(signature)
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I I 13171 Place of Disposition
(address)
.sue
UJ
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of ses 5,0„a11
(
pl e print)
ILI Signature Title (f*ril
O H-1555(07/18)p 1 of 2
1
0...5 3 ;
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home name0 on burial permit
Official Funeral Directors Reg.or License#/