Smith, George NEW YORK STATE DEPARTMENT OF HEALTH s II t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George Smith Male
Date of Death 0 8/01 /2 01 4 Age If Veteran of U.S. Armed Forces,
84 War or Dates Korea
.1 Place of Death Hospital, Institution or
Glens Falls Glens Falls Hospital
Z City, Town or Village Street Address p
Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined El Pending
Illy Circumstances Investigation
tu Medical Certifier Name Title
CI Darushan Soonabala MD
Address 161 Carey Road, Queensbury,NY 12804
Death Certificate Filed District Numbe5�t Recsr umber
City, Town or Village Glens Falls 1
01
0Burial Date Cemetery or Crematory
II 08/04/2014 Pineview Crematory
i;❑Entombment Address
II®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
E= Hold
0 Date Point of
tL Transportation Shipment
ciby Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Vay-Schleich & Meeson Fuberal and Registration Number
Name of Funeral Home 01751
Cremation Chapcls
Address
1075 Long Pond Road, Rochester,NY 14626
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Z.
f
` Permission is hereby granted to dispose of the human mains describ d above as ndic ted.
Date Issued ) Registrar of Vital Statistics gp_R � ` 672)-f
(signature)
District Number Soo I Place 2G- €4
l
I certify that the remains of the decedent identified above were disposed of in accordance w. this permit on:
111 Date of Disposition t f041 Place of Disposition eF aw 6.4 -
(address)
ICU
ta
CC (section) lot number) (("' (grave number)
Name of Sexton or Person in Charge of Premises rr �J[hKM-
r (pl se print)
iii
Signature Title eiVOWOL
(over)
DOH-1555 (02/2004)