Smith, Michael 33
NEW YORK STATE DEPARTMENT OF HEALTH - ' '' 0. 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael Andre Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 23, 2015 70 War or Dates
Place of Death Hospital, Institution or
- City, Town or Village Argyle Street Address Washington Center
Manner of Death IL.] Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name,, Tile
-,,'---- Lf511! S\Cek-e OA--
'` Death Certificate Filed District Number Register Number
City, Town or Village Argyle S 7 S b /5
g ❑Burial Date Cemetery or Crematory
March 2, 2015 Pine View Crematory
❑Entombment Address •
';®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal r '/r_.r Held
O and/or Address
• Hold
Date Point of
❑Transportation Shipment
by Common Destination
Y Carrier
❑ Disinterment Date Cemetery Address
',❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
A Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• a.' Address
.3 Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued .))1s 1 15" Registrar of Vital Statistics ,, ,ii,Qpi ill bA,,A,_.
(signature)
District Number S 77Sb Place C Ny
JJ
f I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 03/02/2015 Place of Disposition Quaker Road Queensbury,NY 12804
✓ (address)
(section) ,f Y .(lot number) (grave number)
'0 Name of Sexton or Perso in Char a of Premises I 4'1 3 #
��j ( lease print)
'. Signature "'-� T Title �� '
(over)
DOH-1555 (02/2004)