Smith, Edward NEW YORK STATE DEPARTMENT OF HFALTF,, 4-
Vital Records Section Burial - Transi ermit
Name First Middle Last Sex
Edward D Smith Male
Date of D th Age If Veteran of U.S. Armed Forces,
/4 1 1
10 d3 62 years War or Dates Air Force
Place of Death Hospital, Institution or
Z. City, TowitAorXjfilla xx Glens Falls Street Address Glens Falls Hospital
ct Manner of Death 0 Natural Cause ❑Accident Homicide Suicide Undetermined Pending
itjCircumstances Investigation
W Medical Certifier Name Title
L Timothy F Murphy Coroner
Address
52 Haviland Ave Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Towrxio ilIR XX Glens Falls 5601 418
[]Burial Date Cemetery or Crematory
Li Entombment 10/07/2013 Pine View Crematorium
Address
Ia.Cjemation Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
2and/or Address
fA
�= Hold
C Date Point of
0,,,❑Transportation Shipment
G! by Common Destination
Carrier
Ei,EiQ Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01441
>_ Address
South Glens Falls, NY R f 63 5 K S►i 70 ail Aye-
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
It
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/07/2013 Registrar of Vital Statistics tf3cyt,A.41^4 t.'>J
(signatur )
District Number 5601 Place Glens Falls 1✓SJ
::::;. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tii Date of Disposition 0hli3 Place of Disposition ,K Q,,y s tett-
(address)
Ui
CC (section) (lot numb) (grave number)
Name of Sexton or Pers n in Charge of Premises t,A -- 3 Iii s
(please print)
10
Signature , L Title Gil"-1►A1—
(over)
DOH-1555 (02/2004)