Smith, Mary NEW YORK STATE DEPARTMENT OF HEALTH +''" 3C-
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Mary Jane Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 22, 2012 89 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Kingsbury Street Address 311 Hartman Road
Wm of Death 0 Natural Cause 0 Accident El Homicide El Suicide riUndetermined ri Pending
U Circumstances Investigation
W' Medical Certifier Name Title
W
Mark Hoffman MD,
Address
420 Glen St. Glens Falls, NY 12801
Death Certificate Filed District Number Registermber
City, Town or Village S 7t0-,L
❑Burial Date Cemetery or Crematory
July 23, 2012 Pine View Crematorium
❑Entombment Address
,Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ElRemoval and/or Held
and/or Address
p': Hold
6 Date Point of
c ❑Transportation Shipment
GO by Common Destination
0 Carrier
Disinterment Date Cemetery Address
ElReinterment 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
I— Remains are Shipped, If Other than Above
2 Address
ec
i a- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ~/-�3 0?0%. Registrar of Vital Statistics 11, . ina
0 / (signature)
District Number 5-71.,,, - Place if.,e
I certify that the remains of the decedent identified above were disposed 1of in accordance with this permit on:
W' Date of Disposition /'l y-1Z, Place of Disposition 4(f l�V. w_, ( f c'ii ti
(address)
I
(.0 to number) (grave number)
�, (section) �(
11-
p :::t:est0n
orPerinCharremises ( leaseprint)6 Title Clf 1,114-1(01j,
(over)
DOH-1555 (02/2004)