Kingsley, Harold NEW YORK STATE DEPARTMENT OF HEALTH l l J
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harold E Kingsley Male
Date of Death Age ' If Veteran of U.S. Armed Forces,
08/0 /2012 67 years. War or Dates
Place of Death Hospital, Institution or
X City, To i -..- Street Address
( �tvt X Clcns Clcns Il�SS HHo ital
0 Manner o- eat' j Natural Cause Accident ❑Homicide 0 Suicide i Undetermined 0 Pending
W Circumstances Investigation
la Medical Certifier Name . Title
Add ar shin Soonabalon M D
s
126 Ski Bowl Drive North Creek, Ny
Death Certificate Filed District Number Register Number
City, TovtaxVihgtxX Glens Falls 5601 377
liii OBurial ate Cemetery or Crematory
['Entombment 08/09/2012 Pine View Crematorium
Address
tCfemation Queensbury, NY 12Rn4
Date Place Removed
Removal and/or Held
�
and/or Address
Hold
U)
Date Point of
05❑Transportation Shipment
Gs by Common Destination
Carrier •
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury. N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'„ Address
CC
W.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/09/2012 Registrar of Vital Statistics L o&) -`Q W
(sign ure)
nil District Number Place
c601 Glens Falls i Iv Y Ja$O'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
U C
1 Date of Disposition �l-it)-t2 Place of Disposition ,, tr,.,. r.,_, rt,,-,
1 (address)
VI
CC (section) (lot num (grave number)
its Name of Sexton or Person in Charge f Premises liritiett--, 144/it
l (please print)
Signature L Title Cri€4 i ao(t
(over)
DOH-1555 (02/2004)