Smith, Katie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit ermit
`s Name First Middle Last Sex
Katie R. Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 9,2016 69 _ War or Dates
Place of Death Hospital, Institution or
f City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
tu Circumstances Investigation
w Medical Certifier Name Title
CI Cleaver
Address
HHHN
Death Certificate Filed District Number Regist r Number
City, Town or Village Glens Falls 5601N5-1
❑Burial Date Cemetery or Crematory
❑Entombment September 12,2016 Pine View Crematory
Address
II Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z [ I Removal and/or Held
and/or Address
F_ Hold
U)
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
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
a:_.:•• Remains are Shipped, If Other than Above
2 Address
re
Permission is here y granted to dispose of the human r mains describe above as i i • ed.
Date Issued I Registrar of Vital St tistics Z' . 4 02'
�j/ (signature)
District Number �"•� Place -�/���J ��
J
H I certify that the remains of the decedent identified above were disposed of in a']cccordanc ith this permit on:
w Date of Disposition 'ffj((i, Place of Disposition ent V a./ r"n,a�o['n++-
W (address)
CO
O (section) 4.1
(lot number (grave number)p Name of Sexton or Person in Charge of Premises 3i+�H
Z (please print)
W Signature 4 • Title C(If (L
(over)
DOH-1555 (02/2004)