Smith, Glendon Douglas / /1....,
it I Li
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Glendon Douglas Smith Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/01/2023 83 Years War or Dates
F— Place of Death Hospital,Institution or
WCity,Town or Village Ticonderoga Town Street Address Elderwood at Ticonderoga
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Frending
al
CICircumstances Investigation
QW Medical Certifier Name Title
James Gabler PA
Address
1019 Wicker St,Ticonderoga Town,New York 12883
Death Certificate Filed Town Of Ticonderoga District Number s Register Number
City,Town or Village 1564 01
Burial Date Cemetery,Crematory or Facility Name
'.... 01/03/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
Removal Date Place Removed
F. and/or and/or Held
N Hold Address
0
O. Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
OReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
N Address
CC
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/03/2023 Registrar of Vital Statistics Tonya M Thompson(ECectronicaCCy Signed)
(signature)
District Number 1564 Place Town Of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition ( I 5- Z3 Place of Disposition I —
�I ,�,cL
2 (address)
W
Co (section) 72(
Jiot numbe (grave number)
gName of Sexton or Person in Charge of 're I ises t''
Z / please print/ /�
Ill Signature Title `Il1lq
DOH-1555(07/18)p 1 of 2
'I65 5
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#