Smith Sr, John 4-58
NEW YORK STATE DEPARTMENT OF HEALTH or _ .4.
Vital Records Section Burial - Transit Permit
.• ; Name First Middle Last Sex
:%:- John E. Smith,Sr Male
fr? Date of Death Age If Veteran of U.S. Armed Forces,
January 27, 2015 62 War or Dates
ram• Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
'r, Craig Emblidge,MD
0
Address
:X Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number ! ,
:r•: City, Town or Village Glens Falls 5601 `1-
..'❑Burial Date Cemetery or Crematory
El Entombment January 29, 2015 Pine View Crematorium
Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
yTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'';j Permit Issued to Registration Number
r: :; Name of Funeral Home Regan & Denny Funeral Home 01444
Address
;;:r 94 Saratoga Avenue, South Glens Falls,NY 12803
. Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above
Address
Permission is hereby g dispose to dis ose of the human remains described above as indicated.
•
rr'; Date Issued f r✓2 9 on Registrar of Vital Statistics to
'r'r: i (signature)
:X: District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition I /AI jr Place of Disposition ,,,r1)., etiborGr-
W (address)
U)
O (section) J (lot numper) (grave number)
pName of Sexton or Person in Charge f Premises K
Z A, ' (please print)
ILI
Signature Title Crtz AWL.-
(over)
DOH-1555(02/2004)