Smith, William NEW YORK STATE DEPARTMENT OF HEALTHif
Vital Records Section I' k 7`urial - Transit Permit
Name First Middle Sex
William O. Male
Date of Death Age If Vet ,of_3 . i rces,
i. December 24, 2016 �( War •
Z Place of Death Hospital, y/ /Y1e //lie Al$fy,, A/. '
W City,Town,or Village Albany Street Address =esidence /2a4'3 /
0 Manner of Death M Natural Cause n Accident n Homicide D Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Paul L. Marra, M.D. Dr.
0 Address
112 State Street, Albany, NY 12207
Death Certificate Filed District Num Register Number
City,Town or Village Albany Z-7 ii TS
n Burial Date Cemetery or Crematory
January 3, 2017 Pineview Crematorium
❑Entombment Address
44 [i Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed s
0 n Removal and/or Held
- and/or Address
I" Hold
0 Date Point of
0 0 Transportation Shipment
0 by Common Destination
Carrier
Date Cemetery Address
h n Disinterment
LI El Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
!= Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
C.
Permission is hereby granted to dispose of the hums ams escribed above as ndicated.
Date Issued 1 Li o/ ((o Registrar of Vital Statistics 12 (/�-
_ J (signat re)
District Number \ 0 I Place Albany,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 01/03/2017 Place of Disposition Pineview Crematorium
2 (address)
W
14 (section)) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises r,l ,�,qt fr
W ( lease print'''
Signature Title CrkilATOL
(over)
DOH-1555 (02/2004)