Smith, Dennis NEW YORK STATE DEPARTMENT OF HEALTH 1'U
Vita:Recor;s Section Burial - Transit Permit
Name First Middle Last Sex
Dennis Brownell Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 21, 2015 70 War or Dates
�- Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
W' Manner of Death 1771Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
C]` Joseph Foote MD,
Address
Rt 4 Hudson Falls, NY 12839
Death Certificate Filed District Number Register Number
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
December 22, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
H Hold
Date Point of
❑Transportation Shipment
U) by Common Destination
Q Carrier
Date Cemetery Address
El Disinterment
❑ 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
0_
W
0' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued )2-Z-2-0/5 Registrar of Vital Statistics LAJC .
(signatu )
District Number 5601 Place 6 k',c Fok l 1 S / L1
I certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
z /2-22-/S
W Date of Disposition 1 -5 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
(section) (lot number) (grave number)
ci Name of Sexton or Perso in Charge of Premises / Gel .6
Z
(please print)
W Signature ` Title C-t-e-moi
(over)
DOH-1555 (02/2004)