Smith, Harold VW
NEW YORK STATE DEPARTMENT OF H ( ! l
Vital Records Section Burial - Transit Permit
Name First M. 1 Last Sex
Harold I. Smith Male
Date of Death Age li Veteran of U.S. Armed Forces,
',' March 1, 2011 86 War or Dates World Warll
iPlace of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
US
ai Manner of Death l Xl Natural Cause n Accident n Homicide Suicide Undetermined 1 Pending
Circumstances Investigation
to Medical Certifier Name Title
Mikhail Mavashev MD
Address
211 Church Street, Saratoga Springs, NY 12866
„, Death Certificate Filed District Number Register lyumber
City, Town or Village Saratoga Springs 4501 C� �.
❑Burial Date Cemetery or Crematory
❑Entombment 3/2/2011 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z 1-1 Removal and/or Held
0 and/or Address
E Hold
N
O _ Date Point of
0. Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home,Inc. 00205
Address
Fa, 24 Church Street, PO Box 500, Lake Luzerne, New York 12846
„_, Name of Funeral Firm Making Disposition or to Whom
,t, Remains are Shipped, If Other than Above
2 Address
tr
Permission is hereby granted to dispose of the human remai s des roitrItif as v dicat
, ,,:.
Date Issued 3/2/2011 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3-I(-i( Place of Disposition Phu Vij CC,vci-Ot C._
(address)
Cl)
0 (section) _ (lot nu r) (grave number)
O Name of Sexton or Person in Charge of Premises (btvi frk ,irtd-
Z, —2—r"l (please print)
W Signature J41) Title e lr- --0fl
(over)
DOH-1555(02/2004)