Smith, Richard D •
[OF
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard D Smith Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/27/2022 65 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death ❑X Natural Cause Accident n Homicide Suicide FlUndetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
G Aqeel Gillani MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 235
Burial Date Cemetery,Crematory or Facility Name
04/29/2022 Pine View Crematory
Entombment Address
EICremation Queensbury Town,New York
Donation
20 Removal Date Place Removed
and/or and/or Held
( Hold Address
an
0
G. Date Point of
(/)❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
a Address
CC
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/28/2022 Registrar of Vital Statistics Megan Aro1in(ECectronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition E 1 Zf 21 Place of Disposition xl,,,c vh... �.,717; + �----
2 1 (address)
W
CC
to (section) (lot number) (grave number)
SName of Sexton or Person in Cha Premises 41L) S
Z (lease print)
W Signature r Title C m
4411,1Z—
DOH-1555(07/18)p t of 2
3 7 "
•
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#