Smith, Pasqua f ; 1107
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
j Name First Middle Last Sex
Pasqua T. Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
':j' June 29,2014 57 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
im Manner of Death X Natural Cause Accident I 1 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michelle Antiles D.O.
Address
17 Main Street,Glens Falls,NY 12801
:;:� Death Certificate Filed District Number Re 'st r tuber
:;:f; City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
CI Entombment July 1, 2014 Pine View Crematorium
Address
❑X Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold '
Cl)
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
;;r Name of Funeral Home Regan Denny Stafford Funeral Home 01443
:;:f Address
53 Quaker Road, Queensbury, NY 12804
K:E.: Name of Funeral Firm Making Disposition or to Whom
i;j Remains are Shipped, If Other than Above
Address
' Permission is hereby granted to dispose of the human remains described above as indicated.
▪ Date Issued 7 I i / / '/ Registrar of Vital Statistics UJ CAAi - Li
(signature)
• District Number 5601 Place Glens Falls Al V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition )-3-Is Place of Disposition . 1 �,..•-t v.:.
W (address
U)
O (section) (let number) (grave number)
p Name of Sexton or Person ' Charge of Premises 4
'Z (phase print)
Signature Title CniiiAderrie
(over)
DOH-1555(02/2004)