Smith, Diane Elizabeth i .\\ 432
NEW YORK STATE DEPARTMENT OF HEALTH LF ,
Bureau of Vaal Records �✓ Burial - Transit Permit
Name First Middle Last Sex
Diane Elizabeth Smith Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/06/2023 67 Years War or Dates
1.., Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address St Peters Hospital
pManner of Death ID Natural Cause Accident El Homicide Suicide riUndetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Anastasios Konstantakos MD
Address
319 S Manning Blvd,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 0043
Burial
Date Cemetery,Crematory or Facility Name
e 01/09/2023 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
IL Date Point of
(I)lTransportation Shipment
5 by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
a Address
CC
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/09/2023 Registrar of Vital Statistics Danie1eSGiaespie(E(ictronicaaySigned)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 P /
W Date of Disposition I I q i 73 Place of Disposition -L �C
2 (address)
W
CIC (section) (lot number) \� (grave number)
Name of Sexton or Person in Charge of Premises /�/1 +^' ' t�{
8 ( ease print)
W Signature Title fine�''R�`(
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ' delivered on , 20
I
^' Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ,' '