Smith, Ruth NE1r°»YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
44 Name First Middle Last Sex
Ruth Fisher Smith Female
7 Date of Death Age If Veteran of U.S. Armed Forces,
- May 8, 2011 86 War or Dates
Place of Death Hospital, Institution or
Et City, Town or Village Queensbury Street Address Stanton Nursing & Rehabilitation Center
Manner of Death km
Lxi Natural Cause El Accident 0 Homicide 0 Suicide ID Undetermined n Pending
Circumstances Investigation
`' Medical Certifier Name Title
Roslyn Socolof, M.D. Dr.
Address
;4 100 Broad Street Glens Falls, NY 12801
Death Certificate Filed Qistrict Number Rvister Number
City, Town or Village (r)c n
Burial Date Cemetery or Crematory
P May 12, 2011 Pine View Cemetery
f ❑Entombment Address
;[Cremation Quaker Road Queensbury,NY 12804
t Date Place Removed
n Removal and/or Held
L and/or
Hold Address
Date Point of
nTransportation Shipment
by Common Destination
Carrier
1 Date Cemetery Address
Disinterment
y Reinterment
Date Cemetery Address
+, Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01098
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
4
i..
Permission is hereb granted to dispose of the human remains described., bove as indicated.
1 Registrar of Vital Statistics _ �j�
Date Issued 91
,------, (signature)
District Number c 6 ') Place ) L.,%`L2f-4--)-06 __C". 1 tsz_fp.S1,00)._
I certify that the remains of the decedent identified above were disposed of in accord ce ith this permit on:
Date of Disposition 05/12/2011 Place of Disposition Quaker Road Queensbury,NY 12804
E (address)
0 Mohican 2A 2
(section) (lot number) (grave number)
Name of Sexton or Person • Charge of Premises Michael Genier
(please print)
Su erintendent
Signature
(over)
Title p
(over)
DOH-1555 (02/2004)