Smith, Joan NEW YORK STATE DEPARTMENT OF HEALTH,' 45°
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joan M. Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/09/2016 80 years War or Dates
}- Place of Death Hospital, Institution or
W City, TXj X)O MOW Glens Falls Street Address Glens Falls Hospital
O Manner of Death Natural Cause �Accident �Homicide �Suicide Undetermined 0 Pending
to Circumstances Investigation
W Medical Certifier Name Title
Gamal Garhy Khalifu M D
Address
100 Park Street Glens Falls, N Y
Death Certificate Filed District Number Register Number
City, T X 4XXr XXX d( Glens Falls 5601 242
.i> ❑Burial Date Cemetery or Crematory
05/10/2016 Pine View Crematorium
❑Entombment Address
OCremation Queensbury, NY 12804
Date Place Removed
0,Z El Removal and/or Held
and/or Address
i= Hold
to
O Date Point of
to❑Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
P O Box 277 Fort Ann, N Y 12827
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Z Address '
IX
LU
P` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/09/2016 Registrar of Vital Statistics (A)
District Number 5601 Place Glens Falls) AI U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ior
tit Date of Disposition 5Jlo//A Place of Disposition s tW ( m+rt ._'
2 (address)
111
C (section) A(lot number (grave number)
0
O Name of Sexton or Person in Charge of Premises t-st a
Z► (phase print)W. /�
Signature a Title
(over)
DOH-1555 (02/2004)