Smith, Roberta 00 YORK STATE DEPARTMENT OF HUAt_i H
,1 ecords Section Burial - Transit Permit
Name i=irst _ Middle last Sex
ROBERTA V. SMITH
Dale of Death Age It Veteran of U.S.Armed Forces,
January 13, 1996 59 War or Dates non
^' Piave of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address
Manner of Death Natural Cause Accident [j Homicide []Suicide ❑Undetermrned El Pending
Circumstances Investigation
Medical Certifier �N1ar e Title
S: �ichard Spitzer, M, .D
Address
Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601 3
Date Cemetery or Crematory
❑Burlal January 15, 1996 Pine VIew Cremator
5cx Address
remation Quaker Road Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
[]Transportation Shipment
p by Common Destination
Carrier
[]Disinterment Date Cemetery Address
[]Reinte'rment Date Cemetery Address
Permit Issued to Registration Number
Sin y
Name of Funeral Horne singleton-Healy Funeral hOm
jG
<. Address t
407 Bay y�
y Road Queensbur NY 12804 •
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, if Other than Above
Address
?< Permission is hereby granted to dispose of the human remains described above as InjAcated.
v Date Issued JAN 15 1996 Registrar of Vital Statistics
(signature)
District Number 5601 place City of Glens Falls, NY 12801
I certify that the remains of the decedent Identified above were disposed of in accordance with this permit on:
I'
Date of Disposition �� Place of Disposition
(address)
0Mr (se ion) (lot number (grave number)
Qfame of Sextor or Person in Charge of Premises__ �4J �Tf�
(please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2
VS-61