Smith, Clara NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Biostatistics -Vital Records Section Burial - Transit Permit
im Name First Middle Last > Sex
CLARA ....S�'aITH................... FEMALE
Date of Death Age If Veteran of U.S.Armed Forces,
Oii
MARCH 7, 1989 100 War or Dates
;Z Place of Death Hospital, Institution or
' City,Town or Village;t.1.1........ .... 9 GLENS FALLS Street Address GLENS FALLS._.HOSPITAL_
. ..........::......:::::::::::::::::::::::::::::::::::::::::: .�.......................................
tom Cause of Death
iii
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III Medical Certifier Name0. Title
:: : ::::::::: : ::J::::.Babe::::. ::::::::::::.::::::........................::::::Medical...Phys ician.....--................................................................
Address
:::::::::::::.:::::::::::::::::_...4,:1 ,ti.1..:BQx...46:,:: Diamond Point, New.::YOrk::::::::....... ................. ....
....... ....................... .. .....
............... .......
•- .th Certificate Filed District Number Register Number
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1010 Town or Village /.e - .,.c -d/ //f
Dat Cemetery or Crematory
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®Burial :.................. Q...................- PINE...VIEW CEMETERY
0 Cremation Address
OUAKER ROAD, QJEEtj.SPTJRY, NEW YnRY 12804
Z Date Place Removed
O El Removal and/or Held
and/or Hold ::::::::::::.::::::::::::::::::::::::::::.:::::..::::::::::::::::::::::::::::::::::::.:::::,::::::::::::::.:._:::::::::::::::::::::::._::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.
:; Address
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aQ Date : iPont::::::::::::::::.:::::::::::::::..:.................................-...............................................................
of
cn. ❑Transportation by Shipment
Common Carrier
Destination
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Disinterment Date Cemetery Address
..........................................:.:::::DateEUX
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Reinterment Cemetery Address
Permit Issued to Registration Number
iiii<ii; Name of Funeral Firm REGAN...&...DENNY FUNERAL...SERVICE,....INC.........__........................................._..02883iiiiiiiiiii ..__.......... ..__........
................................................................:..::....::....::.....:..:........:......:.:::.:..:......:........:..:.....:........:...........::..:............................................................:..:.............................................
Address
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
;,:.:::Name of Funeral Firm Making Dis::::.sition or to Whom::::::.......................................................................................................................................................
Remains are Shipped, If Other than Above
...........................................................................................................................................................................................................................................................................
P Address
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......................._...........................................-_................................................_..................__...........-......._..................._...._.........................._...............
Eiiii Permission is hereby granted to dispose of the huma sins described above as indicated.
`? Date Issued e.T //r Registrar of Vital Statistics 7 "
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District Number 2..��j/ Place2 /,,,Z.Zl. . ,.ed/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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w Date of Disposition 3—r n _�; Place of Disposition Ai 1ST c z? Oc-t•��t c-i,) u r�P,s1,` r��
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Ca (section) (lot number) (grave number)
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LEL6 Name of Sexto rson in Charge of Premises (., ,A p T, P , )1.1 .. S 1. e 1.-
Z (please print)
W Signature C �ty„e Ji , -A.G,.. Title c,1 y0-r-
DOH-1555 (9/86)p 1 of 2(formerly VS-61)