Smith Florence A. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Florence A Smith Female
Date of Death __TAge If Veteran of U.S. Armed Forces,
3/2/2020 81 War or Dates
} Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ti#J Circumstances Investigation
Medical Certifier Name Title
0 Matthew Sean Loftus RPA
Address
Glens Falls Hospital 100 Park Street Glens Falls NY
- Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 i U�
®Burial Date Cemetery or Crematory
❑Entombment March 5,2020 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
pDate Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
h+_ Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued 3 SJ ZC�ZO Registrar of Vital Statistics
ature)
District Number 1�(J Place l -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3/5/2 0 2 0 Place of Disposition 21 Ouaker Rd Oueenghury,, NY 1 2 R
=i (address)
W toHuron 6A 2
IX (section) (lot number) (grave number)
pName of Se on or Person in Charge of Premises C nnn i e C'nPt�Pr
Z (pl se print)
W z Title
Signature
rl
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b) 010372
Receipt
Human remains of delivered On , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
SMITH
NAME Florence Smith `age: 81
Lot Owner:
Louis & Florence Smith
Lot# Grave#
Huron 6A 2
Case:
Concrete
Died: Interred:
3/2/2020 3/5/2020
Funeral Home:
Regan Denny Stafford
Cemetery:
Pine View