Smith, James A 4 lit
NEW YORK STATE DEPARTMENT OF HEALTH Burial - �ar1sit Permit
Vital Records Section
Name First Middle Last Sex
James Arthur Robert Smith Male
sy Date of Death Age If Veteran of U.S. Armed Forces,
°:: December 17,2016 76 War or Dates
Place of Death Hospital, InstitutiorWftrren Center For Rehabilitation And
City, Town or Village Queensbury Street Address Nursing
o Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
tii Circumstances Investigation
�w; Medical Certifier Name Title
0, Roslyn Socolof
Address
9 Carey Rd.,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 I(pq
❑Burial Date Cemetery or Crematory
December 20,2016 Pine View Crematory
0 Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
0 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
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
1 -, Remains are Shipped, If Other than Above
Address
4,- Permission is hereby granted to dispose of the human n d . d a o as i icated.
Date Issued I a..>4).)p1bRegistrar of Vit Statistics
(sign re)
District Number 5(Qs' Place Oft—
certify that the remains of the decedent identified above re disposed of in accor•- e with this permit on:
W Date of Disposition /Z/tilab Place of Disposition ;ndrt,./ af"pr,_,,,
2 (address)
W
U)
CC (section) // ,(lot numb (grave number)
p Name of Sexton or Person in Charge,rof Premises (hr ,F , JtInlb(-
Z (.ease print)
LU /
Signature it ,/ Title ( Nile_
(over)
DOH-1555 (02/2004)