Holman, Jr. Harold NEW YORK STATE DEPARTMENT OF HEALTH if L
Vital Records Section Burial - Traniitilermit
Name First Middle Last Sex
g
Harold F_ Male
U 1 an r.
iiitii Date of Death Age If Veteran of V. Armed Forces,
Sept. 26, 2012 75 War or Dates No
14 Place of Death Town of Dresden Hospital, Institution or
Z City, Town or Village Street Address 63 Dresden Road
Ili
itt Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined 0 Pending
tip Circumstances Investigation
at Medical Certifier Name Title
Heidi Rasmusson MD
Address
Poultney Street Whitehall New York 12887
Death Certificate Filed District Number Register Number
City, Town or Village Town of Dresden 5752 04-12
ni ❑Burial Date Cemetery or Crematory
Oct. 1 , 2012 Pine View Crematorium
di ❑Entombment Address
1lCremation 21 Quaker Road Queensbury New York 12803
Date Place Removed
Z❑Removal and/or Held
and/or Address
F"' Hold
IA
0 Date Point of
pi❑Transportation Shipment
L1 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to J i l l son .Funeral Home Inc. Redo ttraat5 n Number
Name of Funeral Home
Address 46 Williams Street Whitehall New York 12887
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
w
i` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9-,R 6._/ . Registrar of Vital Statistics rn,/ t (,,,_ Atha,
(signature)
< District Number S 75,3., Place jrn 6 Amz
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILL! Date of Disposition 1p l I/12 Place of Disposition g.ILL) l_. t t4l—
(address)
LU
CC (section) (lot num r (grave number)
Name of Sexton or erson in Char of Premises dri J t""e't
G , `
(please print)
Lii. Signature Title Ci t4tr
(over)
DOH-1555 (02/2004)