Smith, James 4/ 511
NEW YORK STATE DEPARTMENT OF HEALTH i , t
Vital Records Section Burial - Transit Permit
t ,
:r▪ r Name First Middle Last Sex
James Smith Male
:: Date of Death Age If Veteran of U.S. Armed Forces,
August 6, 2014 77 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
iliManner of Death
X Natural Cause Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gi Catherine Dawson
Address
;j211 Church St, Saratoga Springs,NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 3�3
❑Burial Date Cemetery or Crematory
August 8, 2014 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
▪ Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
i Address
r 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Al; Remains are Shipped, If Other than Above
I Address
r Permission is hereby granted to dispose of the human remains a bo s ' icated.
:;:f J II
Date Issued P1 8120ILI Registrar of Vital Statistics
w▪ . (signature)
r:: District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ghilly Place of Disposition 641..., C1- to(1•—
i (address)
W
N
O (section) ? (lot numbej (grave number)
p• Name of Sexton or Person in Charge of Premises g1t,It e«+NI.
Z (phase print)
ILI
Signature tL. /(pr- Title G(tavg„
(over)
DOH-1555(02/2004)