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Smith, Peter Wayne -s • 4 P Sia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex w`fr Peter Wayne Smith Male s i Date of Death Age If Veteran of U.S.Armed Forces, 06/19/2018 77 Years War or Dates Place of Death Hospital, Institution or . City, Town or Village Glens Falls Street Address Glens Falls Hospital " Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending NCircumstances Investigation Medical Certifier Name Title Wendy Steinhacker PA = Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 309 El Burial Date Cemetery or Crematory 06/21/2018 Pine View Crematory❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address 7 ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address - 11 Lafayette St,Queensbury,New York 12804 ' Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated, • Date Issued 06/20/2018 Registrar of Vital Statistics 2ip6ertA Curtis(E(ectronicaufy Signed) (signature) District Number 5601 Place Glens Falls, New York rc„ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 4Ilip lig Place of Disposition 1'ji ..., e -a,,._ (address) (section) (Jot numb ) (grave number) Name of Sexton or Person in Charge of Premises � J t,,at (please print) . Signature A ,4_ Title UZI An'I f, (over) DOH-1555 (02/2004)