Smith, Richard K 10- fD
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Poo
Bureau of Vital Records
Name First Middle Last Sex
Richard K. Smith Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/2/2020 88 War or Dates NO-
F Place of Death Hospital,Institution or
Z City,Town or Village Hadley Street Address 6305 SR 9N
Ili
p Manner of Death a Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined 121 Pending
W 0Circumstances Investigation
W Medical Certifier Name Title
f3 Dr.Paul Byron MD
Address
Corinth,NY
Death Certificate Filed District Number Register Number
City,Town or Village Hadley
❑Burial Date Cemetery,Crematory or Facility Name
10/6/2020 Pine View Crematory
ElEntombment Address
QCremation
0 Donation Quaker Rd., Queensbury,NY 12804
dRemoval Date Place Removed
Eland/or and/or Held
F Hold Address
N
0
0. Date Point of
/! Li Transportation Shipment
G by Common
Carrier Destination
Disinterment Date Cemetery Address
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
1.. Remains are Shipped,If Other than Above
2 Address
CC
ti]
Q' Permission is hereby granted to dispose of the human re ins described a ove as i sated.
Date Issued id., 6,al Registrar of Vital Statistics
(signature)
District Number y C31 i Place
I certify that the remains of the decedent identified above were di posed of in accordance with this permit on:
I
Z Date of Disposition /Of l l ZO Place of Disposition "Fn',Vi€__
elth--------
tu (address)
W
Cl)CC (section) (lot numtre (grave number)
0 Name of Sexton or Person in Charge of Premis 4((p pyxd f(
age print)
W Title /'
Signature ^`t
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014676
Receipt
Human remains of : delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
1