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Smith, Dominic Alexander (2)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dominic Alexander Smith Male Date of Death Age If Veteran of U.S.Armed Forces, 12/01/2019 17 Years War or Dates �.. Place of Death Hospital,Institution or Z City,Town or Village Albany Street Address Albany Medical Center Hospital Uj W Mannerof Death ©Natural Cause Accident Homicide Suicide Undetermined ❑Pending U Circumstances Investigation W Medical Certifier Name Title Sonali Bhalodkar MD Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 2556 Burial Date Cemetery,Crematory or Facility Name 12/05/2019 Pine View Cemetery Entombment Address Cremation Queensbury Town,New York Donation ZZ Removal Date Place Removed and/or and/or Held H Hold Address N O Cl Date Point of Cl) Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto Whom Remains are Shipped,If Otherthan Above Address Cr W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/04/2019 Registrar of Vital Statistics DanieCCe S Gi(Cespie(ECectronically Signed) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition D_7-19 Place of Disposition'�j �C,�,� �XYie Lu ,, 11 /address/ W tt y Cl) Action (lot number) (grave number/ 0 Name of Sex o Person in Charge of Premises N l L' /please print/ Z �p uJ Signature F Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 010356 Receipt Human remains of-i 2,`' q;;^' delivered on , 20 T Pine View Cemetery Representing the funeral home named on*ai permit Official Funeral Directors Reg.or License#