Smith, Robert NEW YORK STATE DEPARTMENT OF HEALTH 4 V7
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Robert R. Smith Male
• Date of Death Age If Veteran of U.S. Armed Forces,
February 25, 2017 75 War or Dates 1960-1963
� Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
€1 8. Manner of Death Undetermined Pending
❑X Natural Cause �Accident �Homicide �Suicide
Circumstances Investigation
w Medical Certifier Name Title
Paul Bachman MD
Address
Warrensburg,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5 60 1 2Q
❑Burial Date Cemetery or Crematory
February 27, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZG ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
El
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
• Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Permission is herebygranted to dispose of the human remains described above as indicated.
p
Date Issued 2 2? l l 7 Registrar of Vital Statistics WCA-(1-r Q'
(signature)
District Number 560 Place G Gbv\ s ) . I \ S N (J
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3)( II? Place of Disposition gntV lL*4 t.1)41^atcs)41*-
(address)
W
Cl)
(section) �l (lot number) c�' (grave number)
pName of Sexton or Person in Charge of Premises (,rZ r' 3tn4 tr
Z / ( ease print)
W Signature L �v4�- Title t IM
(over)
DOH-1555(02/2004)