Smith Sr., Robert NtW YOHK S I ATE DEPARTMENT OF HEALTH t'/ 71 j
Vital Records Section l Burial - Transit Permit
/Name First
Middle Last Sex
Sr. Robert E. Smith Male
Date of Death Age }f Veteran of U.S.Armed Forces,
11/24/2017 73 years War or Dates N/a
1- Place of Death Hospital, Institution or
Z009nown or WOWCoxsackie Street Address • Coxsackie Correctional Facility R M U
p Manner of Death DNatural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined ri Pending
.114
U Circumstances Investigation
W Medical Certifier Name Title
G Jeffrey D. Hubbard MD '
Add ss
Albany, New York •
Death Certificate Filed District Number Register Number
GW4own or VilXii@IV Coxsackie 1954 17
OBurial Date Cemetery or Crematory
11/29/2017 Pineview Crematory
❑Entombment Address
OCremation Queensbury, New York
Date Place Removed
ani Removal and/or Held
and/or Address
HoldCII L_
0 Date Point of
0 Transportation Shipment
Q by Common Destination
Carrier
0
Disinterment Date Cemetery Address
O Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of•Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Avenue, Corinth, Ny 12822
• Name of Funeral Firm Making Disposition or to Whom
}-. Remains are Shipped, If Other than Above
Address
CC
W
fl` Permission is hereby granted to dispose of the human remains described ove as indicated.
Date Issued 11/29/2017 Registrar of Vital Statistics i- '_ at• 7Lg y
(signature)
District Number 1954 Place Coxsackie
2 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition /1/30(!) Place of Disposition „v I,,,/ � c
2 (address)
Cl)Li
CC (section) (lot numb (grave number)
O.
Name of Sexton or Person in Charge of P emises �r, -ew�A
z (lease print)
W Signature -t� Title fir,*,
` EMPt--
(over)
DOH-1555 (02/2004)