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Harvey, Norman NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Norman A Harvey MD Male Date of Death Age If Veteran of U.S. Armed Forces, 05/28/2018 98 Years War or Dates Army Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Jennifer Stratton MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 275 kl Burial Date Cemetery or Crematory 06/05/2018 Pine View Cemetery ❑Entombment Address ❑Cremation Queensbury, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/01/2018 Registrar of Vital Statistics W96ertA Curtis(E(ectronica((ySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 6/5/201 aDlace of Disposition Pine View Cemetery Queensbury (address) Mohican #65-A 7 (section) (lot number) (grave number) Name of Se ton or Person in Charge of Premises Connie Goedert (please print) Signature --l_zikeAr Title Cemetery Superintendent (over) DOH-1555 (02/2004)