Smith, Ella 1
NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ella - (yanLiew) Smith Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/1/2015 100 War or Dates
Place of Death Hospital, Institution or
W City,Town or Village South Glens Falls Street Address 36 Nolan Rd.SGF, NY 12803
in Manner of Death®Natural Cause 0 Accident Homicide Q Suicide �Undetermined �Pending
Circumstances Investigation
W Medical Certifier Name Title
0 r/9•YR/cede ,t,�,,•_,2, Ai f
Address , i� @ 62n E,�S
l y ��y y !d Fr) �
Death Certificate Filed 'District ,, j►�•..- Regis er umber
City,Town or Village Moreau i.
❑Burial Date Cemetery or Crematory
12/2/2015 Pineview Creamatorium
❑Entombment Address
4Cremation 21 -4. Road Queensbur N.Y. 12804
Date Place Removed
.'❑Removal
and/or Held
Mrand/or Address
Hold
0 Date Point of
N 0 Transportation Shipment
by Common Destination •
Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Radl off Funeral Home Inc, 1425
I
Address
136 Warren Glens Falls New York 12801
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Ce
a° Permission is hereby granted to dispose of the human rem descri d a ve as Indicated.
Date Issued 1o? d)-.)O!S Registrar of Vital Statistics ,(,rye
I1
(signature)
District Number ZO 9 Place I ,'3( D f NY u, (12rLLL , {LL/, Yd Y
VI certify that the remains of the decedent identified above were disposed of in accordance withv this permit on:
Z z4 i crkmctcir s�
Date of Disposition It 13 i 1 S Place of Disposition „� v
W (address)
Cl)
(section) //f (lot number) (grave number)
pName of Sexton or Person in Charg of Premises /hr:s-'pLretart1
Z (pi se pint)
W Signature Title ��
(over)
DOH-1555(02/2004)
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