Harris, Francis R. -;� /y3
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Francis R Harris —7Male
Date of Death Age If Veteran of US.Armed Forces,
03/01/2020 79 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
W
V Circumstances Investigation
G Medical Certifier Name Title
Kenneth France MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 36
Burial Date Cemetery,Crematory or Facility Name
03/05/2020 Pine View Crematory
Entombment Address
Nil Cremation Queensbury Town,New York
❑Donation
dRemoval Date Place Removed
and/or and/or Held
~ Hold Address
O
IL Date Point of
to ❑Transportation
p by Common Shipment
Carrier Destination
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Narrfe of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition orto Whom
H Remains are Shipped,If Other than Above
Address
cc
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/05/2020 Registrar of Vital Statistics CarornexlJegarde B-rAer(E&-tronw-ff Sy&ed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 3 S 17G Place of Disposition
W
2 (address)
W
W (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of Pr ises r! 1�✓ 1,.4
Z (p se print)
lu Signature Title
DOH-1555(07118)p 1 of 2
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#