Underwood, Harry 1 ) )
NEW YORK STATE DEPARTMENT OF HEALTH — '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harry Floyd Underwood Male
Date of Death Age If V an of U.S.Armed Forces,
12/4/2018 84 W r Dates
f. Place of Death Hos, Institution or
Z City, Town or Village Moreau Stree ddress 1 Tulip Street
W Manner of Death ❑X Natural Cause n Accident I I Homk..e E Suicide Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
O Glen Anderson,PA
Address
Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Town of Moreau 4562 v 7
❑Burial Date Cemetery or Crematory
December 7, 2018 Pine View Crematorium
Entombment Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ U Removal and/or Held
and/or Address
H Hold
Co
O Date Point of
co ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Home 01444
Address
94 Saratoga Avenue,South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
1—, Remains are Shipped, If Other than Above
2 Address
a.
Permission is hereby granted to dispose of the humanan r descri ove as indicated.
Date Issued 3 Registrar of Vital Statistics tat6(1
(sig ature)
District Number 4562 Place Town of Moreau,New York /,AidY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w• Date of Disposition) , It-l' Place of Disposition .f►Int, � :CAA) c c p'(;4
W (address)
N
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises J v„ ,r tS
`Z (please print)
Signature Title ;ifc."Li-lo I
(over)
DOH-1555(02/2004)