Smith, James NEW YORK STATE DEPARTMENT OF HEALTH ; 7 7 ti
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Francis Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 8, 2015 83 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Home
Manner of Death X❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
°a Medical Certifier Name Title
Donald Merrithew, M.D. Dr.
Address
319 Bay Road Queensbury, NY 12804
Death Certificate Filed DistrictW.&-,),
Registumber
City, Town or Village '-/
.'0 Burial Date Cemetery or Crematory
October 13, 2015 Pine View Crematory
El Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
❑ Removal
Date Place Removed
and/or Held
and/or Address
Hold
Date Point of
oTransportation Shipment
by Common Destination
I Carrier
❑ Disinterment Date Cemetery Address
IllReinterment Date Cemetery Address
Permit Issued to Registration Number
- Name of Funeral Home M.B. Kilmer Funeral Home- SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
(4" Permission is hereb granted to dispose of the human remai describes o J- as indicated.
Date Issued Q /jam Registrar of Vital Statistics (tatt / /'
� J L/ (sign:ture)
]7
District Number �� Place 30 ,'i'fl /cLc gel ri)s(gaii nil. /pVd. 2
1; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/13/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) _ (grave number)
Name of Sexton or Person in Charge of Premises t An4 !' �te4�+4-
�/f l/ (Tease print)
Signature (/%/ �//T— Title On
(over)
DOH-1555 (02/2004)