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Russell, Henry NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit ry q N• ame First Middle Last Sex Henry D. Russell Male Date of Death Age If Veteran of U.S. Armed Forces, 1 October 13,2017 83 War or Dates Korean t,,-• Place of Death Hospital, Institution or City, Town or Village Johnsburg Street Address 2942 State Route 8 :iz. Manner of Death Natural Cause Accident Homicide I 1 Suicide Undetermined Pending ALL — Circumstances Investigation la Medical Certifier Name Title Robert Love MD v Address Iron Gate Practice Death Certificate Filed District Number Regist Number City, Town or Village Johnsbur% 5655 %. 4 ❑Burial Date Cemetery or Crematory ❑Entombment October 17, 2017 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date 1 Place Removed ZZ {Removal , and/or Held and/or Address t Hold cn 0 Date Point of N 7 Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address L {Renterment Date Cemetery Address =a P• ermit Issued to Registration Number gi " Name of Funeral Home Alexander-Baker Funeral Home 00037 -:=• Address _ 3809 Main Street,Warrensburg,NY 12885 r& � Name of Funeral Firm Making Disposition or to Whom t- Remains are Shipped, If Other than Above A• ddress TX ta t • Permission is hereby granted to dispose of the human emain descri ve as . ' t d. D• ate Issued t » 1-- l Registrar of Vital Statistics D ature) District Number 5t Place T/O Johnsburg,NY I H certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition /6- /9-17 Place of Disposition /),-1 ev;p,„) C,e_e er.lo/y 2' (address) W N Cd (section) (lot number) (grave number) pName of Sexton or Person in Charge of Premises �) /. a,l GG L4P Z' (please Print) W Signature a, Title L , ma 4-is- (over) DOH-1555(02/2004)