Smith, Emily 1 i
NEW YORK STATE DEPARTMENT OF HEALTH . r ' `
Vital Records Section Burial - TransiPermit
Name First Middle Last Sex
Emily K. Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 2,2017 90 War or Dates
-' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
t Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Ixl II II
w, Circumstances Investigation
di_ Medical Certifier Name Title
G= Melissa Decker
Address
9 Carey Road,Queensbury,NY 12804
Death Certificate Filed District Number Regi$ter Number
t3 City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
January 4,2017 Pine View Crematory
0 Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I 1 Removal and/or Held
and/or Address
L. Hold
Cl)
O Date Point of
NTransportation Shipment
pp by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;`; Permit Issued to Registration Number
=va; 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
S: Address
a
Permission is hereby granted to dispose of the human re ains described ab ve as ind' ated
Date Issued (,)i)b41 31 '/ Registrar of Vital Statistics (-7:2_, � _
111 (signature
District Number 566 / Place -Zei---/-t-,J Cc..--ed
I certify that the remains of the decedent identified above were disposed of in accords a with this permit on:
Z p �
ui Date of Disposition I 1 id(r1 Place of Disposition eac i.r etc*.4t,��
2 (address)
W
U)
CC
0 (section) /`(lot number) (grave number)
Op Name of Sexton or Person in Charge of P emises Gltt•, I�.r ,.'...Ill`
Z (pll ase print)
ill
Signature tid Title Oifirrief._
(over)
DOH-1555 (02/2004)