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Smith Jr., Harold Z NEW YORK STATE DEPARTMENT OF HE4ItH I �' Vital Records Section Burial - Transit Permit It Name First Middle Last Sex Harold P.Smith Jr. Male 151, Date of Death Age If Veteran of U.S. Armed Forces, 01/16/2018 61 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 0 Homicide ❑Suicide 1-1❑Undetermined �Pending Circumstances Investigation Medical Certifier Name Title Matthew Loftus PA Address 100 Park St,Glens Falls, New York 12801 WH- .= Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 28 El Burial Date Cemetery or Crematory 01/18/2018 Pine View Crematory i ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed t ❑Removal and/or Held and/or Address Hold Date Point of --- ❑Transportation Shipment by Common Destination Carrier r4 Date Cemetery Address 0 Disinterment ed ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne, New York 12846 iti Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above z Address ,-:, Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/18/2018 Registrar of Vital Statistics cp6ertA Curtis(E(ectronicatfySigned) (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: L . Date of Disposition I/I$hi Place of Disposition gy,J..) 4-47, • a (address) (section) n (lot number) (grave number) Name of Sexton or Person in Charge of Premises `'�ri+ S"'•t ( lease pant) 4 Signature 1 Title *M .- (over) DOH-1555 (02/2004)