Smith, Jennie , # I.`i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiiil Name First Middle Last Sex
Jennie Margaret Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/11/2011 74 years War or Dates
Place of Death Hospital, Institution or
Z City, Tov i +- Street Address
tii �.4 : Glens Falls Glens Falls Hn-cpital
0, Manner o eat E� atural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
t Circumstances Investigation
at Medical Certifier Name Title
0 David Foote Nun
Address
340 A Main Street Hudson Falls, N Y 12839
Death Certificate Filed District Number Register Number
City, TowiloliMaibrx Glens Fails 5Ani 15
❑Burial Date Cemetery or Crematory
i ; ❑E ombment 01/17/2011 Pineview Crematory
Address
iiiiii
�ematien Queenshiiry, N Y 1>804
Date Place Removed
Z❑Removal and/or Held
and/or
Address�;,;
co
Hold
0 Date Point of
14❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
fiii
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home • 01149
Address
11 Lafayette Street Queensbury. N Y 12804
Name of Funeral Firm Making Disposition or to Whom
jo Remains are Shipped, If Other than Above
Address
Ili
1.1 Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued 01/12/2011 Registrar of Vital Statistics Ik,Li
(signate)
District Number Place
5601 GIPns Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ill Date of Disposition 3Rj i°), Zul I Place of Disposition Pine U,�,-, evrn4 f or wk.__
a (address)
Lu
Mt
Ili. (section) (lot number (grave number)
ilk Name of Sexton or Person in Cha :e of Premises Ai:sk,),,, JP`M
uf-
f I (please print)
Signature �
I1 LL� r.4 Title � ��l l��-
„„„„,„
(over)
DOH-1555 (02/2004)