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Smith, Brian r li S li g NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit rA,:;,. Name First Middle Last Sex Brian G. Smith Male Date of Death Age If Veteran of U.S. Armed Forces, w,��x 09/07/2014 49 War or Dates Plac ath / Hospital, Institution or Cit , Town r Village Bfaat:-Lake ,��CCOyj Street Address Deceased's Residence Man Death J Natural Cause 0 Accident Ef Homicide EI Suicide [1 Undetermined n Pending Circumstances Investigation Medical Certifier Name Title GARY SCIDMORE, jiT"A ddress 6970 St Rte 8 4112USIStelleig, NY 12813 Death Certificate Filed District Number Register Number City,Town or Vittage ilx)/v. CC"- 5�J� 7 f:ZA0 Burial Date Cem?ta Cre 09/08/2014 , '/1��e( J L?e m a/o-i t/ 2,l E]Entombment Address it®Cremation ��--e,Q �b i/f t ,/V y.. ))©// my Date Place Reved ❑ Removal and/or Held and/or Address Hold 40? Date Point of ❑Transportation Shipment ' by Common Destination a> Carrier 4'P-W Date Cemetery Address } Disinterment Renterment Date Cemetery Address V Permit Issued to Registration Number Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141 1; Address 9 Pine St/P.O. Box 455 Chestertown NY 12817 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 1. Address Permission is hereby granted to dispose of the human remains escribed above ads indigated. e Registrar of Vital Statistics Date Issued �' (signature) , District Number z.,Ss-I Place 41;Gerit---- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition q/$liy Place of Disposition U, Crro+:‘,.- (address) (section) �t number) ( di (grave number) Name of Sexton or Person in Charge of Premises f' t4I�Ll-. VI h (Please print) ) it,-• Signature Y art itilitriZ (over) DOH-1555 (02/2004)