Smith, Valerie NEW YORK STATE DEPARTMENT OF HEALTH T+a4(3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Valerie Ann Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/07/2012 64 years War or Dates
t PI of Death Hospital, Institution or
it ow -II Street Address
ner of Death Natural Cause 0 Accident 0 Homicide El Suicide El Un etermined El Pending W.
10
Circumstances Investigation
lig Medical Certifier Name Title
flarci A Gaintti-gruhhs M n
Address •
102 Park St Glens Falls, N Y 12801
D-- 4 Certificate Filed District Number Register Number
`";: owrIIXX Glens Falls 5601 208
a['Burial Date Cemetery or Crematory
05108/2012 Pine View Cemetery
❑Entombment Address
gljEiCvamation Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
i'= Hold
0 Date Point of
Pii El Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
E El;;; Q Reinterment . Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
iiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above •
;; Address
tr
ILL .
Permission is hereby granted to dispose of the human remains described above as,indicated.
ilili Date Issued 05/08/2012 Registrar of Vital Statistics CAA41-12-
(signature
District Number 5601 Place Glens Falls ,/0/ /a $O/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
FO
W Date of Disposition s-1-it Place of Disposition ?Inttkv Crin-if rr,,_-
(address)
ILI
to
c (section) (lot number) (grave number)
Name of Sexton or Person in Charge f Premises �.�� i..r S6 {1-
'� /� � (please print)
Signature /// ///�— Title at4ilikiZV
(over)
DOH-1555 (02/2004)