Smith, Elaine `—' r r 7
NEW YORK STATE DEPARTMENT OF HEALTH et R
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elaine Marie Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 14, 2013 44 War or Dates
I Place of Death Hospital, Institution or
City y TownVillage, or age Glens Falls Street Address Glens Falls Hospital
WManner of Death AccidentEll Natural Cause 0 Homicide Suicide Undetermined Pending
U.
Circumstances Investigation
W Medical Certifier Name Title
Jennifer Phoenix, PA
Address
Hudson Headwaters Fort Edward Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
March 18, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
and/or Address
E Hold
C 3 Date Point of
j, El Transportation Shipment
CO by Common Destination
I6 Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
}- Remains are Shipped, If Other than Above
2 Address
U
13' Permission is hereby granted to dispose of the human remains described above as indicated.
.Date Issued .V i cs ( I:3 Registrar of Vital Statistics LA)CIA.lb- Q, W
(signature)
District Number 5 G0 t Place '6, S c-U k\ s N y
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition3--c)O- u Place of Disposition //wit_ V; dalt074/rhee--
2
W (address)
(40
(section) � /]lot number) (grave number)
a Name of Sexton Per on in r e of Premises S/ /1Gw� i
(pllease print) /] )
al Signature i Title rr � �s � As
T
(over)
DOH-1555 (02/2004)