Smith, Janice NEW YORK STATE DEPARTMENT OF HEALTH 0 Burial 1
Vital Records Section �.. - Transit vermit
Name First Middle Last Sex
Janice Marie Smith Female
• Date of Death Age If Veteran of U.S. Armed Forces,
October 2, 2013 68 _ "'ar or Dates
Place of Death Hospital, institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident 0 Homicide n Suicide 0Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Farhana Kemal, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Numb .� Registrrer
City, Town or Village Glens Falls �N
0 Burial Date Cemetery or Crematory
October 7, 2013 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
,'ID Removal and/or Held
and/or Address
Hold
Date Point of
k Transportation Shipment
by Common Destination
Carrier
• Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
{ Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
• Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the human remains de,%�ribe ab�ave a ' ated.
' Date Issued Q 3 Registrar of Vital Statistics r ���..
1
(signature)
District Number L / Place 6/ ?S f ei/4 Air /2 /
t I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/07/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
.: (section) (lot number (grave number)
Ati
cName of Sexton or Person in harge of Pre ises o Yr than'
(please print)
Signature Title CUM COa.,
(over)
DOH-1555 (02/2004)