Smith, Richard NEW YORK STATE DEPARTMENT OF HEALTH 591
Vital Records Section Burial - Transit Permit
. '' Name First Middle Last Sex
Richard H. Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 13, 2014 86 War or Dates
Place of Death Hospital, Institution or
, City, Town or Village Fort Edward Street Address 11 Hillview Ave
Manner of Death Ij Natural Cause ❑ Accident El Homicide ❑ Suicide 1-1 Undetermined Pending
6-`. Circumstances Investigation
Medical Certifier Name Title
Elizabeth Hutchins,
Address
`� 2 Broad Street Glens Falls NY 12801
Death Certificate Filed District Number Regist Number
Ci , Town or Villa e Fort Edward
0 Burial Date Cemetery or Crematory
September 16, 2014 Pine View Crematory
❑Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
A. and/or AddressHold
Date Point of
Transportation Shipment
by Common Destination
Carrier
;g, t ❑ Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
:: Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r. . ins described b as indicated.
Registrar of Vital Statistics ,bfzL Y `
Date Issued q l�j���'i' I (signature)
District Number6'7L Place 1 �(,(r 5l�± 82jAiJOAJ3
ci I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/16/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A(lot number) (grave number)
Name of Sexton or Person in Charge of Premises arii1 ter SL11N0-
(please print)
Signature it .. Title COMM
(over)
DOH-1555 (02/2004)