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Harvey, Ruth NEW YORK STATE DEPARTMENT OF HEALTH Vitdr Records Section Burial - Transit Permit V Name First Middle Last Sex n.; Ruth Harrington Harvey Female :: Date of Death Age If Veteran of U.S. Armed Forces, August 31,2012 93 War or Dates a.L' Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address 106 Coolidge Ave lit Manner of Death X Natural Cause n Accident n Homicide Suicide n Undetermined n Pending Uf Circumstances Investigation g Medical Certifier Name Tjtl P.' Lori Indelicato j�� Address ,Warrensburg,NY 12885 Death Certificate Filed District Number Register Number City, Town or Village Queensbury 5657 ) / 0 ©Burial Date Cemetery or Crematory ❑Entombment September 10, 2012 Pine View Cemetery Address ❑Cremation Quaker Road, Queensbury, ,NY 12804 Date Place Removed Z Removal and/or Held 9. and/or Address �' Hold N O Date Point of N n Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address n Renterment Date Cemetery Address : ; Permit Issued to Registration Number °`Ha_.' Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom k• ' Remains are Shipped, If Other than Above Z• ' Address k ' Permission is hereby granted to dispose of the human r ains described above as indi ated. Issued _ Registrar of Vital Statistics � ) �i Date ssue 9_ .�„t 9 � (signature) , District Number 5657 Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition 9/1 0/1 2 Place of Disposition Pine View Cemetery W (address) W 65 A Mohican 8 (section) (lot number) (grave number) pName of Sexton or Perso in Charge of Premises Michael Genier Z //� `� _ (please print) W Signature�"UJA, Title Superintendent (over) DOH-1555(02/2004)