Smith, John t AIL
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
JOHN B. SMITH MALE
Date of Death Age If Veteran of U.S. Armed Forces,
01/08/11 79 War or Dates KOREA
}- Place of Death Hospital, Institution or
W City, Town or Village NORTH ELBA Street Address LAKE PLACID ER
p Manner of Death 2Lurrn Natural Cause ❑Accident D Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
a WOODS MrCAHTLL,i Mn
Address
TORN BROWN ROAD, T,AKF PLACID
Death Certificate Filed District Number Register Number
City, Town or Village NORTH ELBA 1560
❑Burial Date Cemetery or Crematory
❑Entombment JAN 13, 2011 PINE VIEW CREMATORY
Address
®Cremation GLENS FALLS, NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
t Hold
Cl)
O Date Point of
tlr #0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home NIB CLARK, INC. 01094
>« Address
2310 SARANAC AVE. , LAKE PLACID, NY
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
it
LEI
fl" Permission is hereby granted to dispose of the human remains described a ove as indicated.
Date Issued 01/09/2 01 iegistrar of Vital Statistics d'LL,r_f_t �( /�La-7e c
(signature)
District Number 1560 Place LAKE PLACID (NORTH ELBA) , NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU• Date of Disposition ;L, 1,Zoi� Place of Disposition At La C m c f44:..--
(address)
LU
tO
CC (section) ) (lot number) (grave number)
CI Name of Sexton or Person in Char of Premises j
rA"�Q1'i-+' ,5 A6{-
1 (please print)
til Signature ) L-- Title C2 A g\'(UL
(over)
DOH-1555 (02/2004)