Harra, Helen NEW YORK STATE DEPARTMENT OF HEALTH '" 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen _ L. Harra Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/09/2015 89 years War or Dates
1. Place of Death Hospital, Institution or
5 City, T Street Address
ok�X�IC� X Saratoga� pings Sa.r Ha�tal
Manner of Death[,Natural Cause 11 Accident ❑Homicide ❑Suicide Undetermined ri❑Pending
L Circumstances Investigation
W Medical Certifier Name Title
a Richard Kim M D
Address
211 Church Street, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, Tom)\IIX Saratoga Springs 4501 19
❑Burial Date Cemetery or Crematory �r
❑Entombment 01/11/2016 f FAO L ( (k�—'
Address � ��
[Cremation . ... 21 (1�►,(/,✓ �c `i II, g
Date Place Removed
gEl❑Removal and/or Held
and/or Address
N
Hold
O Date Point of
CL
to❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 08519
Address
Schroon Lake, N Y
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
1r
1w3
a' Permission is hereby granted to dispose of the human remain be abo icated.
Date Issued 01/11/2016 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I/17_,O, Place of Disposition -gist tif..; Ci�rm4oc: --
2 (address)
W
CO
CC (section) 4dRfJ
lot number) (grave number)
• Name of Sexton or Person in Charge of Premises 3/9
Z► ( ease print)
ill Signature �"` Title (II?
(over)
DOH-1555 (02/2004)