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Smith Jr., Patrick William
} NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Patrick William Smith Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 09/13/2021 35 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Albany Street Address Albany Medical Center Hospital uJ Manner of Death Undetermined Pending W Natural Cause ©Accident �Homicide �Suicide Circumstances Investigation LU Medical Certifier Name Title . CI Antonio Sturges Coroner Address 175 Green Street,Albany,New York 12202 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 2272 ❑Burial Date Cemetery,Crematory or Facility Name 09/15/2021 Pine View Crematorium 0 Entombment Address 0 Cremation Queensbury Town,New York Donation O0 Removal Date Place Removed and/or and/or Held - Hold Address O �- Date Point of N 1-1 Transportation p by Common Shipment Carrier Destination 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67, Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/14/2021 Registrar of Vital Statistics (Danieli"e S Giccespie(ECectronicaCCy Signed) (signature) District Number 0101 Place Albany, 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 9J/j..S./2 i Place of Disposition j/l L v �►/ Cr ,,.4.10CY 2 (address) W Cl)cc (section) (lot number) (grave number) 8 Name of Sexton or Person in Char a of Premises T-cii' e.4' rGS Z (please print) W Signature ' V Title Cfv,e+rl/ DOH-1555(07/18)p i of 2 015146 Public Health Law Sec. 4145(2b) Receipt t Human remains of _ delivered on , 20 • Pine View Cemetery Representing the funeral home named on burial:" emit Official Funeral Directors Reg.or License#