Smith, Margaret H J %a J
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary-aret H. Smi th F e
Date of Death Age If Veteran of U.S. Armed Forces,
1 War or Dates
Place of Death Hospital, Institution or
City, Town or Village FallStreet Address Glens
Manner of Death I—I Natural Cause Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
MD MD
Address
Death Certificate Filed District Number Register Number
City, Town or Village
u •;..r . :Date _ ,, Cemeiery'or Cie" atory `:
❑Burial
Cremation Address
NY
Date ace Removed
F❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Ajj�;Jnterment ,
Date __ Cemetery.Address
» Permit Issued to Registration Number
Name of_Funeral Hom
B. Kilmer- Funeral Heine 010 56
Address
Name o unera irm Ma ing isposi iori or o#10m
Remains are Shipped, If Other than Above
Address -
=' Permission is hereby granted to dispose of the hum a em 'ns described above as indicated.
Date Issued `� ! Registrar of Vital Statistics
(si ature)
District Number_ �(� I Place LSD (,E A ��S— e C'
-[,certify-that the remains of the decedent identified above were disposed of in accordanc with this permit one
W Date of Disposition �� 1 Place of Disposition P 1J'E V i� -oj C R E,44 �Q R &I
W (address)
i�
(section) lot nu'mp r (grave number)
Name of Sexton or Person in Charge of Premises CY A ?v
(please print)
P�
Signature Title li a e/yx ft -to R Lf
DOH-1555 (10/89) p. 1 of 2 VS-61