Haanen, John a , I
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
,f,o Name First Middle Last Sex
igi John L. Haanen Male
Date of Death Age If Veteran of U.S. Armed Forces,
'- March 30, 2017 87 War or Dates Korea
"'"' Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 48 Wincrest Drive
Manner of Death Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Blood,MD
r'<< Address
';> Queensbury,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury, NY 5657 I
®Burial Date Cemetery or Crematory
Aprils, 2017 Pine View Crematorium
❑Entombment Address
❑Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
H Hold
t/N
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
t Address
'''1 53 Quaker Road, Queensbury, NY 12804
i:A Name of Funeral Firm Making Disposition or to Whom
1.>tf Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r mains described a q a as indicated.
ll �J —
Date Issued3� 1 11 Registrar of Vital Statistics C___
(signature)
District Number "' ) Place 1 b t.x-d c
I certify that the remains of the decedent identified above were disposed of' accord with this permit on:
Z
WW Date of Disposition 4/s ZO/7- Place of Disposition Z ,
(addr ss)
ill � 7 ,T)_
et (sectio ,r I (lot number)�9 (grave number)
pName of S ton or Person in Charge of Premises L 1r�- _
Z ase print
w Signatur Lt,t0, Title
(over)
DOH-1555(02/2004)