Smith, Elaine 0
NEW YORK STATE DEPARTMENT OF HEALTH" .. SM
Vital Records Section Burial - Transit Permit
:•A Name First Middle Last Sex
v.:. Elaine Rose Smith Female
: 1 Date of Death Age If Veteran of U.S. Armed Forces,
: December 4, 2015 59 War or Dates
V Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
g Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Fuller MD
'r: Address
:: 100 Park St. Glens Falls,NY 12801
:X▪ Death Certificate Filed District Number�/ Register vrtr
: r: City, Town or Village Glens Falls 6 as
.s❑Burial Date Cemetery or Crematory
December 7, 2015 Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
! Hold
U)
0 Date Point of
NI 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
▪ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above a dicated.
4i:ti. Date Issued %.z,0/2per Registrar of Vital Statistics'
(signature)
District Number ,S-k)/ Place #4 ` /' /02 f 2/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 12_9,.t5 Place of Disposition rPj,IQ ti,`.ew Cr'eni 4 rr',J•OA
2 (address)
W
CO
O (section (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises t r'rn01-4y l? ihele
Z (please print)
W
Signature - GTitle Cre„Kqkae7 Ass4 P
(over)
DOH-1555(02/2004