Smith, Ralph NEW YORK STATE DEPARTMENT OF HEALTH,
NEW 5 3 Z-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ralph Anthony Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 13, 2014 71 War or Dates
ZPlace of Death Hospital, Institution or
w City, Town or Village Queensbury Street Address The Stanton Nursing & Rehab. Center
W Manner of Death X❑ Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Roslyn Socolof MD,
Address
100 Broad St Plaza Glens Falls, NY 12801
Death Certificate Filed Ditr.ipt Number R st r Number
City, Town or Village C. CO c n
❑Burial Date Cemetery or Crematory
August 15, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
p and/or Address
F Hold Pine View Crematorium
09 Date Point of
❑p,, Transportation Shipment
CO by Common Destination
O Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
CC
p. Permission is hereby granted to dispose of the human rem 'ns described aOJ
e s indicated.
Date Issued�31 t\..f am( egistrar of Vital Statistics Q �11 '
(signature)
District Numbe pc'-) Place ( O c.-.--„--, C a i_ _rT t
I certify that the remains of the decedent identified above were disposed of in acc dance ith this permit on:
W Date of Disposition 08/15/2014 Place of Disposition Quaker Road Queensbury, 804
(address)
W';
c (section) // lot number) (grave number)
pName of Sexton or Person in Charge of Premises C�e'.i ✓ .S r+411/ (p/e'ase print)
W Signatures /� Title crXmM��.
(over)
DOH-1555 (02/2004)