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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David Lee Smith Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/08/2022 70 Years War or Dates
t— Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
LU Manner of Death I I g
0 n Natural Cause nAccident �Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
CI Garrett Barr MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 2595
HBurial Date Cemetery,Crematory or Facility Name
11/15/2022 Pine View Crematory
Entombment Address
IIICremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
Date Point of
U)oTransportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
0 Reinterment
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
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/09/2022 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ Place of Disposition ' �.., Z e.
W Date of Disposition fl I b l L (address)
W
U) (section) 4 (lot number) sirwhrt(grave number)
CC
0 Name of Sexton or Person in Charge of Pre is
Z (ple se print)
W Signature Title (0�n►1Pe.
DOH-1555(07/18)p 1 of 2
r
0 I y 05
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#