Smith, Geraldine NEW YORK STATE DEPARTMENT OF HEALTH` —Vital Records Section Burial - TranZit Permit
Name First Middle Last Sex
Geraldine Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 28, 2016 66 War or Dates
P• lace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death xi Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Investigation Pending
Medical Certifier Name Title
Matthew Miles, M.D. Dr. Circumstances
Address
100 Park Street Glens/Falls, NY 12801
Death Certificate Filed District Number 6 Register Number
r
City, Town or Village Glens Falls 5 0 , 6 39
❑Burial Date Cemetery or Crematory
01 O 12011- Pine View CremtTI
,_. ❑-Entombment. Address -1/ ►-"Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
bi` Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
A• ddress
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
,LL Remains are Shipped, If Other than Above
•
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I?4 2 9 /2-0 i 6 Registrar of Vital Statistics v)r-,u^ ,,-NQ
(signature)
_: District Number 5 6U1 Place 6 (aN,S' Ea 5 AA-)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
D• ate of Disposition I / Y/1/ Place of Disposition .21 Quaker Road Queensbury,NY 12804
(address)
g ���(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
�7
( lease print)
Signature Title (REMA"!�K
(over)
DOH-1555 (02/2004)