Smith, John NEW YORK STATE DEPARTMENT OF HEALTH 1 4 Tr)
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John William Smith Male
eli Date of Death Age If Veteran of U.S. Armed Forces,
iiiiiiii 10/05/2017 53 years War or Dates
Place of Death Hospital, Institution or
lit
City, Tom VXX Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ ❑
Circumstances Investigation
at Medical Certifier Name Title
John W Smith Attending Physician
Address
102 Park St Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
>> City, TcXXXX MOM( Glens Falls 5601 518
['Burial Date Cemetery or Crematory
❑Entombment 10/10/2017 Pineview Cemetery
Address
li Cremation Queensbury, N Y
Date Place Removed
❑Removal and/or Held
it Hnd/or Address
ta old
0 Date Point of
tr)❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01821
Address
11 Algonkin Street Ticonderoga, N Y
ilil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILI
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/06/2017 Registrar of Vital Statistics wl
(signature)
Hiii District Number 5601 Place Glens Falls IV V
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ILI Date of Disposition /0 Ii f n Place of Disposition Rig, 4,^s j,,,..
(address)
Ili
fil
CC (section) (lot number)(-- (grave number)
Name of Sexton or Person in Charge of P emises //.,� r J t^4tt
please print)
Si gnature Nem Title lk'thmilYt_
(over)
DOH-1555 (02/2004)