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Smith, Clyde NEW YORK STATE DEPARTMENT OF HEALTH'* - „ Vital Records Section Burial - Transit Permit Name First Middle Last Sex Clyde Elmer Smith Male Date of Death Age If Veteran of U.S. Armed Forces, August 20, 2016 85 War or Dates Korea E Place of Death Hospital, Institution or WCity, Town or Village Queensbury Street Address 8 Brookshire Trace WLIJ Manner of Death m Natural Cause ❑ Accident ElHomicide ❑ Suicide ❑ Undetermined ❑ Pending U Circumstances Investigation W Medical Certifier Name Title 3 Robert Beaty MD, Address fit 100 Broad St. Glens Falls, NY 12801 r Dea • icate File _�l�� District Number ster Number { Ci Town o Village 1.� c171 ,-Qatr• 5eet ( 9cq � ❑Burial Date Cemetery or Crematory August 22, 2016 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address E Hold U) Date Point of ck. Li Q Transportation Shipment CO by Common Destination Q Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2" Address W; IL Permission is hereb granted to dispose of the human re C31au� ' s descri ed aboire indicatled. a --C , C Date Issued � Registrar of Vital Statistics -L- --___Th (signature) District Number 5601 Place C z) w,. c)f t�QQ�y-zS`, I certify that the remains of the decedent identified above w e disposed of in accordan,a wit, this permit on:2. I-. �hvi e() Grp�. W Date of Disposition 08/ 2016 Place of Disposition QLSaker Road Queensbury,NY 1284 2 (address) W co ce (section) lot number) (grave number) pName of Sexton o e • Ch rge of Premises �1,..-1 rant C��r✓t6,-v4_.e z (pleas print) W Signature Title cre-i'''! ?P' (over) DOH-1555 (02/2004)