Smith, Gerald NEW YORK STATE DEPARTMENT OF HEALTH - .4t bis
Vital Records Section F Burial - Transit Permit
Name First Middle Last Sex
Gerald W. Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/07/2012 66 years War or Dates 1964-68
Place of Death Hospital, Institution or
5 City, Tg glr j(* Saratoga Springs Street Address Saratoga Hospital
Manner of Death Natural Cause 0 Accident ❑Homicide El Suicide Undetermined El Pending
i1J Circumstances Investigation
W Medical Certifier Name Title
CI Richard Kim M D
Address
211 Church Street, Saratoga Springs, N Y 12866
Death Certificate Filed ' District Number Register Number
City, T9 Q,( r MOW Saratoga Springs 45.1 531
❑Burial Date Cemetery or Crematory
['Entombment Pine View Crematory
Address
(Cremation Queensbury N Y
Date Place Removed
Z ❑Removal and/or Held
and/or Address
Hold
41)
0 Date Point of
fiti❑Transportation Shipment
G! by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander- Baker Funeral Home 00035
El Address
Warrensburg, N Y (7$g s- m 0 9 t1 t circet-
:z
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
2 Address
it
w
:. Permission is hereby granted to dispose of the human remai cribed above as indicated.
Date Issued 12/07/2012 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III
U
Date of Disposition IZ-11-12 Place of Disposition �,� jvw +Yir►vic)nu4—
2 (address)
lLE
CO
Ili (section) (lot number) f (grave number)
ci Name of Sexton or Person in Charg of Premises 1 so 1_/
L/,� - f _ (please print)
Signature Title CII% tlf'lr.-
(over)
DOH-1555 (02/2004)