Smith, Ruth NEW YORK STATE DEPARTMENT OF HEALTH P 1°c
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 29, 2015 92 War or Dates
Place of Death Hospital, Institution or
ZCity, Town or Villagenreau Street Address
a Manner of Death❑x Natural Cause ❑Accident Homicide Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Eileen Spinelli ANP—BC
Address
9 Care, Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Moreau 4562 25
ffi❑Burial Date Cemetery or Crematory
June 1, 2015 Pine View Canetery
El Entombment Address
X❑Cremation Qceensbury, NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
0 Date Point of
Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
ni Name of Funeral Home M.B. Kihrer Funeral [the 01078
Address
136 fain Street, South Glens Fells, NY 12803
Name of Funeral Firm Making Disposition or to Whom
1.44 Remains are Shipped, If Other than Above
Address
#r
l
Permission is hereby granted to dispose of the human remainsdescribe above aS indicated.
Date Issued June 1, 2015 Registrar of Vital Statistics jat4./(
(sign t re)
District Number 4562 Place Tear, of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition (o(31 t S Place of Disposition
2 (address)
ttti
CC (section) ,/ (lot number) (grave number)
Name of Sexton or Person Charge of Premises
Z it( ease print)
Signature Title l(Lrtin6} '
(over)
DOH-1555 (02/2004)