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Smith, Rachel Ann -----: _ it kr L(7/ NEW YORK STATE DEPARTMENT OF HEALTH . Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Rachel Ann Smith Female Date of Death Age If Veteran of US.Armed Forces, 05/17/2023 92 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing p Manner of Death ❑X Natural Cause Accident 0 Homicide ESuicide Undetermined ri Pending W Circumstances Investigation W Medical Certifier Name Title CI Jennifer Donovan DO Address 152 Sherman Ave,Queensbury Town,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 77 Burial Date Cemetery,Crematory or Facility Name 05/19/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address CO 0 O. Date Point of (I)ETransportation Shipment 5 by Common --Carrier Destination Disinterment 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 H Remains are Shipped,If Other than Above 2 Address CC W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/18/2023 Registrar of Vital Statistics Caroline.7fi1Tegarde Barber(ECectronica1TySigned) (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: I— ,--_, 4....._ W Date of Disposition s hI t �Z3 Place of Disposition � . (address)L W NCC (section) (lot number) (grave number) gName of Sexton or Person in Charge of Premises / t_ If z �_-%" ( ease print/ W Signature ,e Title (i i DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of • delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#