Smith, Malcolm NEW YORK STATE DEPARTMENT OF HEALTH el 1 gl
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Malcolm Conklin Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 6, 2015 86 War or Dates Navy
,,, Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address The Pines Of Glens Falls
Manner of Death ❑X Natural Cause n Accident n Homicide n Suicide n Undetermined n Pending
tti
Circumstances Investigation
i Medical Certifier Name Title
0, Melissa Decker,MD
Address
Warren Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number �l
City, Town or Village Glens Falls,NY 5601 w
❑Burial Date Cemetery or Crematory
February 9, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
I" Hold
Cl)
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Address
1
EL Permission is hereby granted to dispose of the human re sins des ibed abo€e as indica d.
Date Issued Q� /LYf�, j/S Registrar of Vital Statistics 2'(jvJ el-, ,4 �
111 / (signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were di posed of in accordance with this permit on:
IH
Date of Disposition 2/f II is" Place of Disposition -01itL (r "„
2 (address)
W
CO
O (section) dotnumbV,. (grave number)
p Name of Sexton or Person iiChar e of Premises I r
W ���1 (p ase print)
Signature Title Ci Walt
(over)
DOH-1555(02/2004)