Smurphat, Sr. William NEW YORK STATE DEPARTMENT OF HEALTH j
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Thomas Smurphat Sr. Male
- Date of Death Age If Veteran of U.S. Armed Forces,
January 27, 2012 49 War or Dates Other
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death 0 Natural Cause ❑ Accident ❑Homicide El Suicide ❑Undetermined El Pending
Circumstances Investigation
W1 Medical Certifier Name Title
0" Robert W Sponzo MD,
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 Li Z
❑Burial Date Cemetery or Crematory
January 31, 2012 Pine View Crematorium
❑Entombment Address
*° ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
0, and/or Address
E Hold Union Cemetery
in Date Point of
❑il
Transportation Shipment
CA by Common Destination
'0 Carrier
Date Cemetery Address
❑ Disinterment
❑ 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
Ep
Remains are Shipped, If Other than Above
2 Address
,t
Lit
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1 3 o/1 z Registrar of Vital Statistics w CA -,Q kik 7
(signature)
,� 6 l�>`S •\\s, N �,?
District Number 5601 Place
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t J`! Date of Disposition Z/t /!Z Place of Disposition P...U c.„1 6w forwL
M (address)
co
to (section) (lot number) (grave number)
z0• Name of Sexton or Pers n in Charge o Premises r•sk � vi*
(p/ease print)
LU Signature Title Cew mP f OII7
(over)
DOH-1555 (02/2004)