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Smith, Earl 71/41 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section ' • Burial - Transit Permit Name First Middle Last Sex Earl B. SMith Male Date of Death Age If Veteran of U.S. Armed Forces, 1 2/1 1 /2 01 5 61 War or Dates No i- Place of Death Hospital, Institution or WCity, Town or Village Saratoga Springs Street Address Saratoga Hospital W Manner of Death©Natural Cause El Accident ❑Homicide ❑Suicide El❑Undetermined El❑Pending Circumstances Investigation W Medical Certifier Na e Titlb Iddrtst4f :> Death Certificate Filed District Nu er 11, I ...c,� 1--' '-• •er City, Town or Village Saratoga Springs libUI ❑Burial Date Cemetery or Crematory 12/14/2015 Pine View Crematory ❑Entombment Address Cremation Queensbury, NY 12804 Date Place Removed Z ❑Removal and/or Held 2 and/or Address E= Hold U) 0 Date Point of irt❑Transportation Shipment a by Common Destination • Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home 01079 Address 82 Broadway, Fort Edward, NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address tr lit P.` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 1 2/1 2/1 5 Registrar of Vital Statistics �► s9gnature) jk-- �r�n Place District Number ' City of Saratoga Springs, NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 W Date of Disposition i2 Ii5 jic' Place of Disposition gt, V*, 7r7"4-tortri- 2 (ass) tlt CA CC (section) i (lot number) (grave number) DName of Sexton or Person in Charge f Premises / 1 1 ►- 3 1 tot z (please print) Signature Title fl li<- (over) DOH-1555 (02/2004)