Smith, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John L. Smith,III Male
Date of Death Age If Veteran of U.S. Armed Forces,
• July 1,2018 34 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ui
• Manner of Death Undetermined Pending
Natural Cause Accident I �Homicide Suicide
Ut Circumstances Investigation
�j= Medical Certifier Name Title
0 Timothy E.Murphy Mr
Address
• 52 Haveland Ave.,Glens Falls,NY 12801
E Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 3 2,6
❑Burial Date Cemetery or Crematory
El Entombment July 6, 2018 Pine View Crematory
Address
Ei Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZRemoval and/or Held
and/or Address
I' Hold
co
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
• 3809 Main Street,Warrensburg,NY 12885
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 1( 5/2.Di% Registrar of Vital Statistics W Z '
e (signatu )
District Number E 601 Place 6 ,5 -- r N 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition 7f i la Place of Disposition f.U .-0 4,; ,
W (address)
U)
O (section) (lot number) (grave number)
p• Name of Sexton or Person in Charge of Premises /Z J,r J,i 1..'t
Z (pl ase print)
W'
Signature Title (YirM211112
(over)
DOH-1555 (02/2004)