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Smith, Wayne NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle '4 Last Sex Wayne B. Smith Male Date of Death Age If Veteran of U.S.Armed Forces, January 30,2006 59 War or Dates Vietnam Place of Death Hospital, Institution or z City,Town or Village City of Glens Falls Street Address Glens Falls Hospital ILI G Manner of Death 0 Natural Cause Accident El Homicide El Suicide ID Undetermined El Pending Circumstances Investigation V Medical Certifier Name Title LU Gary Scidmore Coroner Address 6930 State Rt.8,Brant Lake,NY 12815- Death Certificate Filed District Number Register I ujn�er City,Town or Village Glens Falls 5601 �! El Burial Date Cemetery or Crematory 2/2/2006 Pine View Crematory ❑ Entombment Address 0 Cremation Queensbury,NY Date Place Removed Z 0 Removal and/or Held o and/or Address I... Hold ao Date Point of ❑ Transportation Shipment CO by Common Destination 0 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00036 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom }„ Remains are Shipped, If Other than Above - Address re aPermission is hereby granted to dispose of the human r ains cribed aloveas ii sated - ,'/ �� y Date Issued 2-2-06 Registrar of Vital Statistics / '° signature) District Number 5601 Place Glens Falls,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I-- Wz Date of Disposition 2--Z--©4r Place of Disposition l p/A a -6 G R t✓�+d KA v .�. (address) W (section) (lot number) (grave number) On Name of Sexton or Person in Charge of Premises �4 R+{ Cd-12-A-N-1-- Z (please print) W Signature C l ��c- Title CR 2 DOH-1555 (02/2004) (over)