Loading...
Smith, Amy . 1 H 3q NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Amy Loureen Smith Female Date of Death Age If Veteran of U.S. Armed Forces, May 17, 2016 42 War or Dates Place of Death Hospital, Institution or w'r- City, Town or Village Fort Edward Street Address 24 Lydius St. Manner of Death ❑Natural Cause Ei Accident Homicide El Suicide 1-1 Undetermined X❑ Pending Circumstances Investigation W Medical Certifier Name Title * N. Balasubraniam MD, Address New Scotland Ave Albany, NY 12205 Death Certificate Filed District Number 5,,-- Register Number City, Town or Village 0 Burial Date Cemetery or Crematory May 31, 2016 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z Removal and/or Held O and/or Address 1 Hold CO Date Point of eL El Transportation Shipment CO by Common Destination 0 Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 I Remains are Shipped, If Other than Above • Address W Permission is hereby granted to dispose of the humaCre 'ns described a e i icated. Date Issued t(D Registrar of Vital Statistics (signature) District Number 5 ) Place Ed-WOACI HI certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W` Date of Disposition 05/31/2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W CO Ce (section) (lot number (grave number) pName of Sexton or Person in Charge of Premises ATLI" .+r��` Z lease print) Ili Signature a � Title i '. (over) DOH-1555 (02/2004)