Smith, Michael Wilford Sr. - ,
t c 1—
� , Burial - Transit Permit
NEW YORK STATE DEPARTMENT OF HEALTH 1._.F
rBureau of Vital Records
Name First Middle Last Sex
Michael Wilford Smith Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/14/2022 78 Years War or Dates
i— Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 18 Cherry Street,Glens Falls,New York 12801
Ip Manner of Death ❑X Natural Cause IllAccident ❑Homicide Suicide Undetermined Pending
U Circumstances Investigation
ILI Medical Certifier Name Title
G Gerard Abess MD
Address
3 lrongate Center,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 322
Burial Date Cemetery,Crematory or Facility Name
06/17/2022 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
Donation
O❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
Cl)OTransportation
Q by Common Shipment
Carrier Destination
o
Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
W
LL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/17/2022 Registrar of Vital Statistics Megan NoCin(ECectronicaCCy 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:
I—
W Date of Disposition G—/'j z. Place of Disposition ? fj& V:e� e/-. l410 CAA
2 (address
W
Cl) (section) �(lor nrber/ (grave number)
Q ,'/,
8 Name of Sexton or Person in Ch ge of Pre es K/4rfi-0��
z � (please print)
W Signature !/ Title efs`t415
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) ,) :1.
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#