Smith, Bruce NEW YORK STATE DEPARTMENT OF HEALTH
Vitas Records Section Burial - Transit Permit
,..7...., Name First Middle Last Sex
Bruce More Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 7, 2012 91 War or Dates
Place of Death Hospital, Institution or
T City, Town or Village Queensbury Street Address The Stanton Nusing and Rehabilitation
Manner of Death❑ Natural Cause ❑ Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
_" Medical Certifier Name Title
ALL' Roslyn Socolof, M.D. Dr.
yr t, Address
100 Broad Street Glens Falls, NY 12801
Death Certificate FiledDistrict Number is er Number
City, Town or Village Queensbury (.9 c
®Burial Date Cemetery or Crematory
October 9, 2012 Pine View Cemetery
0
f Entombment Address
0Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
-iDate Point of
❑Transportation Shipment
by Common Destination
Carrier
"_ Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
"; Name of Funeral Home M. B. Kilmer Funeral Home 01079
= Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
_:_, Remains are Shipped, If Other than Above
a.° Address
Permission is hereby++ granted to dispose of the human remains described,above as indicated.
Date Issued l d 1 cj Ioo l a Registrar of Vital Statistics Sc_Q , C �
(signature)
District Number Cpc fl Place / )1.A ,—, OC 0 n S
�: I certify that the remains of the decedent identified above were disposed of in acco with this permit on:
rr Date of Disposition 10/09/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Mohican 2 A 1
(section) (lot number) (grave number)
•
is Name of Sexton or Person i Charge of Premises Michael Genier
(please print)
Signature, P " �iNnr.c�. Title Superintendent
(over)
DOH-1555 (02/2004)