Smith, Donald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
_ Name First Middle Last Sex
Donald James Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
ry December 19,2017 83 War or Dates US Navy
Place of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street AddressLLI Glens Falls Hospital
Manner of Death Natural Cause Accident Homicide n Suicide Undetermined n Pending
Circumstances Investigation
Medical._Certifier Name Title
\ `' --- -��-`C \�lJ
Address
Death Certificate Filed ,N....„)....
District Number Register Number//.
51 City, Town or Village Glens Falls,NY 5601 l9
❑Burial Date Cemetery or Crematory
El Entombment December 22,2017 Pine View Crematory
Address
IN Cremation Queensbury,NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold 4
CO
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
1 1 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
r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
it Date Issued i Z / 2z/t 7 Registrar of Vital Statistics W C) - _e
(signatu )
District Number 5lD ` Place •-} ( , �x ITC,,) II I� \ �bvi
I certify that the remains of the decedent identi led�above were disposed of in acco nce with this permit on:
g Date of Disposition /2/z J/7 Place of Disposition )D i e v,-} e..p2 rna-r'viy
// / (address)
W
U)
X (section) (lot number) (grave number)
QName of Sexton or Perso ,n Chafge of Premises J CA_ t a-✓c / ,.ram/6 �
tZ i' (please print)
Signature Title L 7-4_ c.id r-
(over)
DOH-1555(02/2004)