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Smith, Frank A NEWYORK STATE DEPARTMENT OF HEALTH Burial Transi �13 t Permit Bureau of Vital Records Name First Middle Last Sex Frank A.Smith Male Date of Death Age If Veteran of U.S.Armed Forces, 04/30/2020 95 Years War or Dates WWII F. Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc pManner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending LU 0 Circumstances Investigation LU G Medical Certifier Name Title John Quaresima MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Villa a Fort Edward 5755 39 ❑Burial Date Cemetery,Crematory or Facility Name 05/01/2020 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held ~ Hold Address fA O a Date Point of fA ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom F. Remains are Shipped,If Other than Above Address W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/02/2020 Registrar of Vital Statistics Aimee Mahoney(EfectronicaffySiyned) /signature/ District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Place of Disposition Lctz— (address) W N Im (section) (lot (grave number) Name of Sexton or Person in Charge of Premises A r,I nk-mA � Z (p ase print) W Signature L./t 4=- Title 4ij1^kTOK DOH-1555(07/18)p 1 of 2