Smith, Daniel eir
NEW YORK STATE DEPARTMENT OF HEALTH r 1
Vital Records Section Burial - Transi lDermi
Name First Middle Last Sex
Daniel T. Smith Male
ii Date of Death Age If Veteran of U.S. Armed Forces,
r{
June 23,2016 76 War or Dates
r' ; Place of Death
i Hospital, Institution or
City, Town or Village Glens Falls Street Address 20 Elm Street Apartment 602
Manner of Death R Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r : John Delmonte
Address
f:
V 3 Care Lane Suite 300, Saratoga Springs,NY 12850
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 3 2..
❑Burial Date Cemetery or Crematory
June , 2016 Pine View Crematorium
❑Entombment Address
I Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
Cl)
p Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
cedo• Permit Issued to Registration Number
:r: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
: Address
rr: 53 Quaker Road, Queensbury,NY 12804
▪rK• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
A.: Permission is hereby granted to dispose of the human remains described above as indicated.
"•r:: Date Issued 6 /2 116
$' Registrar of Vital Statistics Li-'�� .Q_-fr��; (signatu )
District Number 5601 Place Glens Falls j tJ Le
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition CP 1740. Place of Disposition FOIL 4.414.—.
2 (address)
W
CO
te (section) (lot n}imber) (grave number)
Q Name of Sexton or Person in Charge of Premises fctf�j G.' �ir
Z n, (pjT��ase print)
w %/Q e`�T.E 1*f4�rL
Signature Title
(over)
DOH-1555(02/2004)