Harris, Shirley 4 # gi
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
r ; Name First Middle Last Sex
.; Shirley L. Harris female
r ;, Date of Death Age If Veteran of U.S. Armed Forces,
s 11/18/2017 82 War or Dates n/a
::: Place of Death
QueensburyHospital,re tution or 18 Farr Lane
.:c City, Town or Village Street Address
;;� Manner of Death [X Natural Cause n Accident I 'Homicide n Suicide I Undetermined Pending
::ti Circumstances Investigation
;_."e Medical Certifier Name Title
`�'k Rita All NP
rAddress
{r�: 48 East St. Fort Edward NY
h:i
'ter Death Certificate Filed District Number Register Number
r f City, Town or Village Queensbury
❑Burial Date Cemetery or Crematory
11/21/2017 Pine Viewm Crematory
❑Entombment Address
ix Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
0 Date Point of
I I Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
r:: Permit Issued to Registration Number
f Name of Funeral Home Regan Denny Stafford 01443
: r: Address
r.. 52 (�1uv ueensbury, NY ►Z�O�I
fr Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ains described bove as indicated.
rfc Date Issued I I ia-J IdCA Registrar of Vital Statistics 4 ._ j .��
'.}„ (signature)
District Numb s S Place J O
} I certify that the remains of the decedent identified above were disposed of in accords ith this permit on:
� Date of Disposition 11/Z'�1 1� Place of Disposition fha),,r ( 0-
{ll, (address)
CO.
0 (section) (lot number) c (grave number)
Z Name of Sexton or Person in Charge of Premises
W (Obese print)
Signature /1 Title MiEM/VW
(over)
DOH-1555(02/2004)