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Smyth, Kevin Peter 111 ' itloz—? NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kevin Peter Smyth Male Date of Death Age If Veteran of U.S.Armed Forces, 12/19/2023 70 Years War or Dates Vietnam F Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 4 Homer Avenue, Queensbury Town, New York 12804 WI p Manner of Death IZI Natural Cause Accident El Homicide ESuicide Undetermined ❑Pending UCircumstances Investigation QMedical Certifier Name Title Curtis Gedney MD Address 454 Glen Street,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 190 Burial Date Cemetery,Crematory or Facility Name MIMI 12/21/2023 Pine View Crematory Entombment_ Address ©Cremation Queensbury Town,New York DDonation 0❑Removal Date Place Removed - and/or and/or Held U) Hold Address 0 O. Date Point of U)❑Transportation p by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address EiReinterment 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 I— Remains are Shipped,If Other than Above g Address CC a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/21/2023 Registrar of Vital Statistics Caroline 7fiCdegarcfe(Bar6er(Electronically 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: Z Date of Disposition iif�I�3 Place of Disposition 1T&iFv-T-F 61 iRc Aim+n.--- , W 2 (address) W EC U) (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises ' fh°+ L- iff Z (pll se print) Wfr-1(Signature /� Title liS41�I — __.__._ DOH-1555(07/18)p 1 of 2 - i 7 B 7 r 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#