Smith, Marilyn E..
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex X,,`;, Maril n C. Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 3, 2017 85 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 43 Ridge Street
Manner of Death n
1Natural Cause Accident Li Homicide n Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Anthony Petracca MD
:;. Address
3 Irongate Center,Glens Falls,NY
n Death Certificate Filed District Number o Register Number
go City, Town or Village Glens Falls, NY
®Burial Date Cemetery or Crematory
❑Entombment January 7, 2017 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
85 n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'M Permit Issued to Registration Number
4` ; Name of Funeral Home Regan Dennytafford Funeral Home 01443
g Y
'• Address
f,r.
{fi:: 53 Quaker Road, Queensbury,NY 12804
I. r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
iin Date Issued 1151 Z01)? Registrar of Vital Statistics W C R v6-'-f
(signature)
NO
District Number 5 b(j ) Place 6 l ^S Fcr \\5 1Jmg
Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 1 /7/201 7 Place of Disposition Pine View Cemetery, Queensbury, NY
W (address)
U) Hudson 3 18B 3
(section) (lot number) (grave number)
Q• Name of Sexton or Person in Charge of Premises Connie L. Goedert
Z '{ G�.. (please print)
W Signature . . Title Cemetery Superintendent
(over)
DOH-1555(02/2004)