Smith, BonnieNEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records
ULF Burial - Transit Permit
Name First Middle Last
Sex
Bonnie M. Smith
Female
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/02/2019
61 Years
War or Dates
Place of Death
Hospital, Institution or
W
City, Town or Village Hudson Falls Village
Street Address 17 Alma Avenue, Hudson Falls Village, New York 12839
Q
Mannerof Death Natural Cause ❑ Accident Homicide ❑ Suicide Undetermined Pending
V
Circumstances Investigation
GMedical
Certifier Name Title
Christopher Mason DO
Address
100 Park St, Glens Falls, New York 12801
Death Certificate Filed
District Number
Register Number
City, Town or Village Hudson Falls Village
5726
15
❑ Burial
Date
Cemetery, Crematory or Facility Name
Entombment
10/03/2019
Pine View Crematory
Address
X Cremation
Queensbury, New York
Donation
z
Removal
Date
Place Removed
and/or
and/or Held
~
N
Hold
Address
O
a
N
Transportation
Date
Point of
p
by Common
Shipment
Carrier
Destination
❑ Disinterment
Date
Cemetery Address
❑ Reinterment
Date
Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home
01443
Address
53 Quaker Rd, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/02/2019 Registrar of Vital Statistics 6)vntG,.4Oardin (!ElectronicaY Signed%
(signature/
District Number 5726 Place Hudson Falls Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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WJQ
>
Date of Disposition 3 Place of Disposition
W
(address)
W
N
(section) (lot number/ (grave number)
GName
of Sexton or Person in Charge of Premises ^t'7
Z
(pl se print)
W
Signature Title
DOH-1555 (o7/18) p t of 2
Public Health Law Sec. 4145(2b) 012576
Receipt
4 20
Human remains of \i '0 delivered on
J
Pine View Cemetery
Official
Representing the funeral home named oyabMOM-Dermit
Funeral Directors Reg. or License #