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Demarest, Harold W. # �j NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First FM iddle Last Sex Harold W Demarest Male Date of Death Age If Veteran of U.S.Armed orces, 01/10/2020 94 Years Waror Dates 194 1946 f. Place of Death Hospital,Institution or W City,Town or Village Fort Edward Village Street Address 325 Broadway 16, Fort Edward Village, New York 12828 W Manner of Death © Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending Circumstances Investigation WMedical Certifier Name Title 0 Bryan Smead MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 4 Burial Date Cemetery,Crematory or Facility Name 01/14/2020 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation Z Removal Date Place Removed 0 and/or and/or Held Hold Address N ❑Transportation Date Point of Ek by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped,If Other than Above 2 Address W d Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/13/2020 Registrar of Vital Statistics Aimee 94ahoney(ECectronicaCCy Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition Place of Disposition �� J � -+r r. UJI (address/ W Q (section) pot nu m (grave number) Name of Sexton or Person in Charge of Premises �I-A,.L (pf se prrnt) W Signature 4 — Title 69 DO H-1555(07118)p 1 of 2 Public Health Law Sec. 4145(2b) 0 ` 0 1 3 2 4. Receipt Human remains of -. delivered on , 20 �� i Pine View Cemetery r Representing the,funeral home named on burial permit Official Funeral Directors Reg.or License#