Harris, Mildred NEW YORK STATE DEPARTMENT OF HEALTH (OU 1
Vital Records Section . ! , i r Burial - Transit Permit
'' Name First Middle Last Sex
Mildred S. Harris Female
Date of Death Age If Veteran of U.S. Armed Forces,
Dec. 1 7, 2 01 1 69 yr s. War or Dates no
j Place of Death Hospital, Institution or
City,' ow •r Village Fort Ann Street Address 1410 Patton Mills Rd.
Manner of Death®Natural Cause ❑Accident 0 Homicide �Suicide Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
ifl Max Crossman MD. (Coroner s Physician)
Address
h' Health Ctr_ , PoultnPy St_ r Whiteha4l, NY. 12887
Death Certificate Filed District Number Register Number
M City, own 3r Village Fort5754 (p
Date Cemetery or Crematory
❑Burial Dec. 19, 2011 PineView Crematorium
Address
OCremation Queensbury, NY.
Date Place Removed
0 Removal and/or Held
n and/or Address
EiHold
Q Date Point of
OS❑Transportation Shipment
EPS by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiiiii Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
iN
Address
18 George St. , Fort Ann, NY. 12827
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 ab• ,e i inicated.
liii Date Issued l a—l�-// Registrar of Vital Statistics ` 1
(sigrrire
im District Number 5754 Place Town of Fort Ann, NY.
I certify that the remains of the decedent identified above were dispose fin accordance with this permit on:
f- I I
5 Date of Disposition at r, xi( Place of Disposition „�y°to-) C itoru-
(address)
LU
N
C (section) 4 (ot number) (grave number)
GName of Sexton or Pers in Charge of remises (; .r �v).it
g (please print)
t. Signature 41 Title CiQE M11vida._
(over)
DOH-1555 (9/98)