Smith, Helen NEW YORK STATE DEPARTMENT OF HEALTH *641,
Vital Records Section Burial - Transit Permit
` '- Name First
Middle Last Sex
Helen Virginia Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 28, 2015 93 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death❑ Natural Cause El Accident El Homicide n Suicide ❑ Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gt_i R. ici/;o, /i-1 P.
Address
3 C rokl 0 edc. Ct/ 6/eqs ��,ll� N!
Death Certificate Filed District NumbeL� Registe luumb
City, Town or Village ! R
0 Burial Date Cemetery or Crematory
July 28, 2015 Pine View Crematorium
0 Entombment Address
z ®Cremation Quaker Road Queensbury,NY 12804
Al' Date Place Removed
Removal and/or Held
and/or Address
Tr'� Hold Moss Street Cemeter
y
i Date Point of
;i C Transportation Shipment
by Common Destination
Carrier
5 Date Cemetery Address
1.0 Li Disinterment
0 Reinterment Date Cemetery Address
ei
r k 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
ti Remains are Shipped, If Other than Above
Address
IL
3, Permission is hereby granted to dispose of the human remains described above ass indicated.
Date Issued 71 2-t / /5 Registrar of Vital Statistics WC,t' "� � __ _
/� (signature
District Number 560 ) Place 6 u1JV\5 f G1 „s ,
,f
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
iv u.ec-a Cre.n e,e "
tj: Date of Disposition 07/28/2015 Place of Disposition uaker Road Queensbury,NY 12804
all (address)
tom`..
(section) (lot number) (grave number)
Al Name of Sexton ors Person in Cha e of Premises Bfz
c.i_-�;'-"/ "1 � (please print)
;LUG Si nature Title ���"� V,
(over)
DOH-1555 (02/2004)