Smith, Laura NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
- Name First Middle Last Sex
Laura Louise Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/14/2018 87 Years War or Dates
Place of Death Hospital institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Deathial Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
I Medical Certifier Name Title
Fl Wendy Steinhacker PA
Address
k.
• 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 343
['Burial Date Cemetery or Crematory
07/16/2018 Pine View Crematory
❑Entombment. rem 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
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
1 j
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
, Address
136 Main St,S Glens Falls,New York 12803
rel
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LE
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/16/2018 Registrar of Vital Statistics gg6ertA Curtis(EfectronicaffySigned)
a
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
_-_ Date of Disposition 71 I g jig Place of Disposition .P,,U..Pi e,,, o.,,`
(address)
(section) /(loot t number) C (grave number)
Name of Sexton or Person in Charge of Premises 6 r� L J���tl
(pleas print)
0.
Signature 461 4 Title lilt left ri,
(over)
DOH-1555(02/2004)