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Holland, Harry go NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Secti'osi "-- --, Burial - Transit Permit Name First Middle Last Sex Harry R. Holland Male Date of Death Age If Veteran of U.S. Armed Forces, Dec. 19, 2015 87 yrs. War or Dates ' 50- ' 54 f- Place of Death Hospital, Institution or ILtCity, Town or Village Granville Street Address Haynes House of Hope Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Iti Circumstances Investigation LU Medical Certifier Name Title._ Cc.;1 -kl-er rti Address dvl ? V+ g4. i 49 \ 5-1- l-e--f- V t 6 5 77 5 Death -• ficate Filed District Number Register Number >: City, own it Village Granville S 9 S LP 9 Z, ❑Burial Date — Cemetery or Crematory ❑Entombment ' c2 I a 1 !f cW /'� PineView Crematorium Address ®Cremation Quaker Rd. , Queensbury, NY. 12804 Date Place Removed Z Removal and/or Held P.;❑and/or „ Address L Hold IA 0 Date Point of CI" 0 Transportation Shipment C by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01 1 1 7 Address 18 George St. , Fort Ann, NY. 12827 Name of Funeral Firm Making Disposition or to Whom Jo.. Remains are Shipped, If Other than Above Address ir ill IL Permission is hereby granted to dispose of the human remains described a ove as indicated. Date Issued 13131 pDf.s Registrar of Vital Statistics signature) District Number 5vistaPlace Town of Granvilc?Os.c_ NY. l22 s3 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition )2-21-t C Place of Disposition ,f�h 2 U re,.,(/ C rairklovy (address)/ tli ta CC (section) (lot number) (grave number) ct Name of Sexton or so in Charge of Premises ci t ii ct-el u-rrl ci-c_I Z (please print) la Signature Title C-re Meaket '— (over) DOH-1555 (02/2004)