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Harriman, Robert NEW YORK STATE DEPARTMENT OF HEALTH I t .! it 21 1 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Robert Paul Harriman Male Date of Death Age If Veteran of U.S. Armed Forces, April 15, 2016 67 War or Dates I• Place of Death Hospital, Institution or WCity, Town or Village Gansevoort Street Address 350 Gum Springs Rd. Cl Manner of Death j Natural Cause 0 Accident 0 Homicide Suicide r Undetermined Pending U, Circumstances Investigation Wes' Medical Certifier Name Title Mark Doyle, Address 135 North Rd. Gansevoort, NY 12831 Death Certificate Filed District Number Register Number City, Town or Village ow. d j 0 Burial Date Cemetery or Crematory April 18, 2016 Pine View Crematorium Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Z Removal and/or Held Li and/or Address F.- Hold Moss Street Cemetery Date Point of ❑Transportation Shipment 0) by Common Destination Ci Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address IX [t. Permission is hereby granted to dispose of the human remains escribed abo as indi ated. Registrar of Vital Statistics / Date Issued �/������ 9� ���h� �/��/ (signet District Number (/c--,Cj Place l / 1lVf 1fil/7 9/ I-- I certify that the remains of the decedent identified above wej disposed of in accordance with this permit on: W Date of Disposition 04/40,2016 Place of Disposition Quaker Road Queensbury, 12804 W (address) 0) It (section) (lot number) (grave number) p Name of Sexton o e on 'n Charge of Premises .3 u i:Q 1 t 'm C' Z (please print) W Signature Title e—ca--r7471e' (over) DOH-1555 (02/2004)