Goldsmith, William 4-1;9
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Frederick Goldsmith Male
Date of Death Age If Veteran of U.S. Armed Forces,
"' 09/05/2017 92 Years War or Dates 1942-1945
.- Place of Death Hospital, Institution or
le. City, Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
et Manner of Death rmibiNatural Cause 0 Accident El Homicide 0 Suicide ITUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
#tt Rick Teetz MD
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 427
[]Burial Date Cemetery or Crematory
09/11/2017 i Pine View Cremation
DEntombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Z❑Removal and/or Held
F and/or Address
fA Hold
Date Point of
Q Transportation ; Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped, If Other than Above
2 Address
1
U
LL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/06/2017 Registrar of Vital Statistics yorn PTia,uk ,ErectronicarrySigned-
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11)Z In Place of Disposition P,vV , at+..•
(address)
L
ta
Cg (section) 4(lot number) (grave number)
aName of Sexton or Person in Charge f Premises Slmit
(ple a print)
in
Signature _ Title CPt
(over)
DOH-1555(02/2004)