Smith, Bryan Dennis NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bryan Dennis Smith Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/03/2021 63 Years War or Dates 1976-1979
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death � Undetermined x Pending
W Natural Cause Accident 1__I Homicide ❑Suicide ❑
Circumstances Investigation
W Medical Certifier Name Title
0 Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 21
Burial Date Cemetery,Crematory or Facility Name
01/15/2021 Pine View Crematory
0 Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a Date Point of
(I) Li Transportation
Q by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/14/2021 Registrar of Vital Statistics (P6enyindrew Curtis-(EkctranicalySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I/j S JZ l Place of Disposition `t ' V —_UJ
r�
2 (address)
W
N Cr (section)
(lot number (grave number)
` J
SName of Sexton or Person in Charge" remises
Z (please print)
W Signature Title to vW L
DOH-1555(07/18)pi.of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on 1 , 20:
•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ,