Smith, Harley NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
................Har...eY-....................:......::::...::::...::,::::::: :.:::::.:::::::::._:._::::::::::::::::..::::::::::::Smith
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Date of Death Age
If Veteran of U.S.Armed Forces,
War or Dates no
Place of Death Hospital, Institution or
City,Town or Village City of Glens Falls Street Address Glene Falls Hospital
ausef Death
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C o
' i cardioqenic shock
a Medical Certifier Name Title
GregoryFarry MD......:::-I.-:.:..-,::::::::::::::::::.:l.:-....':........:.::..............:::::::....:::::::::::.:::;.........::::..............::::::::.:::::::..
Address
91 Saratoga Avenue, South Glens Falls, N.Y. 1280
Death Certificate Filed District Number Register N mbar
City,Town or Village City of Glens Falls
Date Cemetery or Crematory
❑Burial
.1... 88 ...............::::>:.:::.1?kne:: : eW.::Cr m ttoriu a:......::::::::::::::::....::.......:.....:::::::.::::,:::::::::::::
Cremation Address
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Zi Date Place Removed
ld ❑ Removal and/or Held
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H and/or H Address
>a. Date Point of
cn []Transportation by Shipment
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Common Carrier
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Destination
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Disinterment Date CemeteryAddress
..Date Cemetery Address:::::...................................................................................................
Reinterment
Permit Issued to Registration Number
Name of Funeral Firm 0:2.883.
Regan and. Denny.... Fune�a1:::.Suc...:.,.:.:Uzic:..::::::::::::::::::.:: .::::::::
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Address
` ........_...............40.. y.,::::N.e ....York.1.2-804....:..........:...................::::::........::::::..._........... ......:.......::::::.:..........
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Name of Funeral Firm Making Disposition or to Whom
" Remains are Shipped, If Other than Above
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a Address
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Permission Is hereby ranted to dispose of the human re ' s described a ove as indicated.
« Date Issued Registrar of Vital Statistics 0
14.t' (signature)
District Number ol, Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition Place of Disposition �/t/��`GI��.� C� // T
tt!> (address)
tWn (lion) (lot number) (grave number)
QC
pi Name of Sexton or Person in Charge of Premises �
Z (please print) / T
W Signature Title 7
DOH-1555(9/86)p 1 of 2(formerly VS-61)