Harney, James Edward . a. I/ f01-)
NEW YORKSTATE DEPARTMENT OF HEALTH t Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James Edward Harney Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/03/2020 87 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
111
Manner of Death ❑X Natural Cause 12 Accident ❑Homicide ❑Suicide ❑Undetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
Abigail Macomber PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 448
❑Burial Date Cemetery,Crematory or Facility Name
10/05/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
HN Hold Address
0
d Date Point of
(f) ❑Transportation
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
❑Reinterment
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
1-. Remains are Shipped,If Other than Above
"g Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/05/2020 Registrar of Vital Statistics R96ertAnrlrew Claris g/ctronicafSrgnet9
(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:
Z Date of Disposition j01+4,1 to Place of Disposition r l•,,. ZitOnt,_
(address)
W
N (section) (lot number) (grave number)
Cr1')1 '- SaytAiti
0 Name of Sexton or Person in Charge of P emises r'
(Ate print)
Z /
IL Signature Title tI' 11 —
DOH-t555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 114 0 A 9
Receipt
Human remains of delivered on , 20
{
Pine View Cemetery Representing the funeral home named on burial permit 1
Official Funeral Directors Reg.or License#