Smith, William NEW YORK STATE DEPARTMENT OF HEALTH ' ' 1 W 607
Vital Records Section Burial - Transit Permit
.: Name First Middle Last Sex
William C. Smith Male
' Date of Death Age_ If Veteran of U.S. Armed Forces,
5' July 12,2015 48 War or Dates
Place of Death
t=] Hospital, Institution or
Z City, Town or Village T/O Minerva Street Address 38 Morse Memorial Highway
tzi Manner of Death Natural Cause I I Accident [ I Homicide X Suicide Undetermined Pending
14.1
Circumstances Investigation
Wz Medical Certifier Name Title
O Francis Varga MD
Address
PO Box 768,Lake Placid,NY 12946
• Death Certificate Filed District Number Register Number
City, Town or Village 1557 a
❑Burial Date Cemetery or Crematory
❑Entombment July 14, 2015 Pine View Crematory
Address
El Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
F" Hold
U)
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
I I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:] Permit Issued to Registration Number
h Name of Funeral Home Alexander-Baker Funeral Home 00037
4, Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I-. Remains are Shipped, If Other than Above
2 Address
w
4--Permission is hereby granted to dispose of the human mains described aboveas indicated.
-1 Date Issued 07/13/2015 Registrar of Vital Statistics lam. ,ce da 1 -fix--.0 v
(signature)
;] District Number 1557 Place T/O Minerva,NY
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 71►ilic. Place of Disposition .gttk�, --1191,...,
2 (address)
W
CO
pre (section) XII.,(lot number) (grave number)
Name of Sexton or Person in Charge of Premises 1,att
zase print)
tu
Signature % Title /i1t.p119l''/
(over)
DOH-1555 (02/2004)