Smith, Walter Russell I
4
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Walter Russell Smith Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/24/2022 80 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
,p Manner of Death ❑X Natural Cause Accident lj Homicide Suicide Undetermined nPending
✓ Circumstances 'Investigation
Medical Certifier Name Title
Jennifer Donovan DO
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 124
Burial Date Cemetery,Crematory or Facility Name
08/26/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
• Removal Date Place Removed
and/or and/or Held
H Hold Address
N
O
d Date Point of
N Transportation
by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
Ei
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
f. Remains are Shipped,If Other than Above
2 Address
IX
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/25/2022 Registrar of Vital Statistics Caroline 1fildegartfe Bar6er(Electronicalry Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition f �����-a- Place of Disposition pie., .16,
2 (address)
W
(section) (tot number) (grave number)
Name of Sexton or Person in Ch rge of Premises J-ttr►tr/
Z /please print)
W Signature _. Title (rt./h4P.4(
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on >I 1 , 20 '^
Pine View Cemetery Representing the funeral home named on 9urPapermit
Official Funeral Directors Reg.or License# '