Smith, Kristine R I I V
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kristine R.Smith Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/28/2023 56 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Warrensburg Town Street Address 18 Oak Street,Warrensburg Town,New York 12885
p Manner of Death ❑Natural Cause Accident El HomicideSuicide Undetermined ❑X Pending
Circumstances Investigation
C.) Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Warrensburg District Number Register Number
City,Town or Village 5660 2
Burial Date Cemetery,Crematory or Facility Name
01/31/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
~
N Hold Address
0
O. Date Point of
N Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg, New York 12885
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
M Address
W
G. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/31/2023 Registrar of Vital Statistics Pamela M Lloyd iECectronicallySigned)
(signature)
District Number 5660 Place Town Of Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z .---
W Date of Disposition 21 z I LS Place of Disposition (address)
W
CC CC (section) (lot number) ` (grave number)
8 Name of Sexton or Person in Charge of Pre s
2 /pl e print/
W Signature / — Title 1
DOH-1555(07/18)p 1 of 2
� �A ....�' �r �.✓ ands
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on t, , 20
l /
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#