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Smith, James I e . s it -7JJ NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit -- Name First Middle Last Sex James Vale Smith Male Date of Death Age If Veteran of U.S. Armed Forces, October 15, 2016 58 War or Dates /9}(o -20041 Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 11 Argyle Street Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending (.3 Circumstances Investigation W Medical Certifier Name Title Rita All, Address .. Death Certificate Filed District Number Register Number , City, Town or Village Fort Edward 51 a i i 0 Burial Date Cemetery or Crematory October 20, 2016 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held and/or Address Hold - Date Point of ❑Transportation _ Shipment es by Common Destination C Carrier k Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address w Permission is hereby granted to dispose of the human 'ns described a o a 'n 'cated. l Registrar of Vital Statistics �` �Date Issued ��` �1-��O 9� �-Ctk) (signatur District Number 55 Place + 1u9' 7 LJ(� t -1 J(� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 10/20/2016 Place of Disposition Quaker Road Queensbury,NY 12804 141. (address) OY (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises C�rttit Si. 44 al Signature L`i'_ (ple se print) g Title (over) DOH-1555 (02/2004)