Harris, Vernon s # 50
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vernon L. Harris Male
:war Date of Death Age If Veteran of U.S. Armed Forces,
ar, January 18,2016 73 War or Dates
'';I
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital& Nursing Home
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
121 Medical Certifier Name Title
Derek Smith
Address
Death Certificate Filed District Number Register Number
a= City, Town or Village C/O Saratoga Springs 4501
El Burial Date Cemetery or Crematory
/ / Q'/4° Pine View Crematory
0 Entombment Address
Ni Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
co
0 Date Point of
N 1 i Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
,,, Permit Issued to Registration Number
n= Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
:,; 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
iit.. Remains are Shipped, If Other than Above
Address
1
x .2 Permission is here y granted to dispose of the human remai e ri d aide indicat
Date Issued I jI'? 9D//0 Registrar of Vital Statistics (signature)
zy District Number Place
__ 4501 C/O Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in`accordance with this permit on:
Z �1 rv.—
w Date of Disposition lho%/Is Place of Disposition
2�V
2 (address)
W
U)
W (section) / (lot numbe�r.! (grave number)
pName of Sexton or Person in Charg of Premises /A ,,wL J`w t
Z n^ I (please print)
Signature Title lVMCila -
(over)
DOH-1555 (02/2004)