Smith, Judson Lewis Jr. / -
NEW YORK STATE DEPARTMENT OF HEALTH _ Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Judson Lewis Smith Jr. Male
Date of Death Age If Veteran of US.Armed Forces,
11/11/2022 84 Years War or Dates National Guard
Place of Death Hospital,Institution or
ZCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
WMedical Certifier Name Title
0 David Foote MD
Address
340A Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 573
RBurial Date Cemetery,Crematory or Facility Name
11/15/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
CL Date Point of
(/)IIITransportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
a Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/15/2022 Registrar of Vital Statistics Megan.Notin(Efectronicaffy 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:
Date of Disposition MIS" I27_ Place of Disposition _L 2}---
IIJ
2 (address)
W
Cl) (section) d (lot number) (grave number)
8 Name of Sexton or Person in Charge o es o (""-- , -1 AV 11-
Z ease print)
W Signature Title (IM/tl
DOH-1555(07h8)p 1 of 2
•
L.
p _S
Public Health Law Sec. 4145(2b)
Receipt
Human remains of r delivered on , 20
Pine View Cemetery Representing the funeral home named on pur)al permit
Official Funeral Directors Reg.or License#