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Smyth, Erica NEW YORK STATE DEPARTMENT OF HEALTH X / If Z Vital Records Section Burial - Transit Permit 57,5 Name First Middle Last Sex Erica Joyce Smyth Female Date of Death Age If Veteran of U.S. Armed Forces, December 30, 2016 25 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital �P Manner of Deathm livi Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation . r Medical Certifier Name Title Michael Sikirica , Dr. Address 50 Broad Street Ste 1 Waterford, NY 12188 Ni Death Certificate Filed District NumbNumiDer Register rt City, Town or Village Glens Falls 6 a/ j ❑Burial Date Cemetery or Crematory January 6, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 '' Date Place Removed ❑ Removal and/or Held and/or Address E Hold Date Point of ❑Transportation Shipment by Common Destination < Carrier t rx ❑ Disinterment Date Cemetery Address �. El Reinterment Date Cemetery Address li Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address , E 136 Main Street, South Glens Falls NY 12803 ;, . 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 abovel as indica ed. Date Issued t ) 312 z j'l Registrar of Vital Statistics LA) �). Y� Vl'���` (signature) District Number �b©I Place 6 �nS A\,1 S ,� f I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 01/06/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number) (grave number) , Name of Sexton or Person in Charge,;of Premises 74st- c•4llr ( se print) Signature tr :'e7 Title 10‘111-10e- (over) DOH-1555 (02/2004)