Smith, Edward NEW YORK STATE DEPARTMENT OF HEALTH _ -A gib
Vital Records Section E . , Burial - Transit ermit
Name First Middle Last Sex
Edward W. Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 6, 2011 1 90 I War or Dates World War II
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls , Street Address Glens Falls Hospital
11.1
• Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
lit Circumstances Investigation
jj Medical Certifier Name Title
a Susanne Rayeski Dr.
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number I Re t�� ber
City, Town or Village Glens Falls 5601
❑Burial 1 Date Cemetery or Crematory
September 8, 2011 Pine View Crematorium
Entombment Address
Ei Cremation 21Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I I Removal ; and/or Held
O and/or Address
U) Hold 1
O Date I Point of
N Transportation I Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
Reinterment 1
I
Permit Issued to Registration Number
Name of Funeral Home Sullivan-Minahan & Potter 1 01646
Address
4• 07 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
°.I: Remains are Shipped, If Other than Above
°N' A• ddress
li
,tit
Permission is hereby ranted to dispose of the human remains d scribed ove i icated.
Date Issued 0rp'20// Registrar of Vital Statistics Li ..
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ill I(I Place of Disposition Qi•wu►eu arrbncV
2 (address)
W
CO
IX
(section) (lot numb (grave number)
Q• Name of Sexton or Person in Charge o Premises �r Ni r ti,. 14"
Z (please print)
W /L
Signature �C Title ZQVAr0
(over)
DOH-1555(02/2004)