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Smith, Diana M NEW YORK STATE DEPARTMENT OF HEALTH (LF) z C Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Diana M.Smith Female Date of Death Age If Veteran of U.S.Armed Forces, 03/11/2023 77 Years War or Dates 1— Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc W0 Manner of Death ❑Natural Cause IllAccident ❑Homicide Suicide nUndetermined ❑Pending W U I—ICircumstances Investigation W Medical Certifier Name Title CI Rick Teetz MD Address 131 Lawrence St,Saratoga Springs, New York 12866 Death Certificate Filed City Of Saratoga Springs District Number Register Number City,Town or Village 4501 166 ▪Burial Date Cemetery,Crematory or Facility Name 03/14/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York ▪Donation 0❑Removal Date Place Removed and/or and/or Held F- Hold Address N 0 o- Date Point of U) Transportation p by Common Shipment Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above S` Address IC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/14/2023 Registrar of Vital Statistics Dillon Moran(Electronically Signed) (signature) District Number 4501 Place City Of Saratoga Springs I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Ililld 13 Place of Disposition 1L 01-.---- W 2 (address) Ill U) CC (section) (I (lot number) sov.i (grave number) 0 Name of Sexton or Person in Charge, remises /� (ease print)/ W Signature L Title ` KA��`2 DOH-1555(07/18)pi of 2 dr . 016794 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Represent}'ng the funeral home named on burial permit Official Funeral Directors Reg.or License#