Smith, Patrick Apr 11 2017 12:06PM Hans Funeral Home 5184896513 ' ' i page 1 #
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NEW YORK STATE DEPARTMENT OF HEALTH • p
Vital Records Section Burial - Transit Permi
,A_ Name First Middle Last Sex
i Patrick Dwight Smith Male
' Date of Death Age If Veteran of U.S.Armed Forces,
r. A'rii 9 2017. 52 War or Dates
. Place of Death Hospital, Institution or
..,s City,Town or Village Albany StrAddress Albany.Medical Center,Hospital
Manner of Death a Natural Cause n Accident El Homklde n suicide: Q Undetermined ; D Pending .
Circumstances Investigation
r Medical Certifier Name ilwTitle
f•
Address
r/a suet,/c 7-, /9/Z.,.�j. �/ ) aI
nth Certificate Filed. District Number Register N mber
Cit .•wn or Village /lan..y / v/ try
-" ❑Burial Date // Cemetery or Crematory T
April 12,2017 Pine View Crematory
Entombment Address
J Cremation 21 Quaker Rd.,Queensbury,NY 12804
.. Date - Place Removed
cZ 0 Removal and/or Held
i and/or Address
Hold
Date Point of
Q• Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
kt []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 re y granted to dispose of the human remains de abed a stve I,di -1.:-,1..
0.Date Issued tk Registrar of Vital Statistics t I � r 4�_fa
(signature)
District Number M ( Place ( ' Attan �,
certify that the remains of the decedent Identified above were disposed
se of in accordance with this permit on:
Date of Disposition (I )13 iii Place of Disposition iiJ' V- -
(address) 1
(section) fy (lot number (grave number)
Name of Sexton or Person in Charge of Premises
.�y,,, '
N. 1 t�e Print) 1
SignatureN.
4 The t l*#11,\(v+2
_J
(over)
DOH-1555(02/2004)