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Smith, Dominic Alexander 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 F.. Place of Death Hospital,Institution or WCity,Town or Village Albany Street Address Albany Medical Center Hospital p Mannerof Death © Natural Cause Accident Homicide Suicide ❑Undetermined Pending W Circumstances Investigation U 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 z Removal Date Place Removed and/or and/or Held ~ Hold Address N O IZ Date Point of N Transportation p by Common Shipment 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 or to Whom F- Remains are Shipped,If Other than Above 2 Address lx 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 G'iCCespie(ECectronicaffy 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: F- Z Date of Disposition >,D.'S-19 Place of Disposition - , J�C,v r�1C W (address) W y U) than (tot number) (grave number) O �N� IE 0 Ch L• ��1� � Name of Sex o Person in Charge of Premises (please print/ Z W Signature Title �s j p 0 A—e DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 010356 Receipt Human remains ot..LL-',I delivered on , 20 T Pine View Cemetery Representing the funeral home named on b*ial permit Official Funeral Directors Reg.or License#