Harwood, Ethan NEW YORK STATE DEPARTMENT OF HEALTH R 100
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ethan A. Harwood Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/23/2015 26 years War or Dates
f!, Place of Death Hospital, Institution or
Z City, To \ftlina C Saratoga R .rings Street Address Sarato a Hos ital
Manner of Death,Natural Cause Accident �Homicide �Suicide Li Undetermined ❑Pending
W. Circumstances Investigation
tu Medical Certifier Name Title
Susan Hayes- Masa Coroner
Address
40 McMaster St, Ballston Spa, NY 12020
Death Certificate Filed District Number Register Number
City, Toxin \AIj X Saratoga Springs 4501 260
<i ['Burial Date Cemetery or Crematory
i'> Entombment 05/29/2015 Pine View Cemetery
Address
[ Cremation Queensbury N Y
Date Place Removed
Z❑Removal and/or Held
and/or Address
E=` Hold
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0 Date Point of
Transportation Shipment
C3 by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 0044R
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
tit
P` Permission is hereby granted to dispose of the human remair,e d€s ri• • abwiff a ' dicated.
: Date Issued 05/26/2015 Registrar of Vital Statistics ' •
(signature)
District Number 4501 Place Saratoga Springs
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition I. /31/5- Place of Disposition Zed..., ( —{vim
a (address)
la
Cl)
lc (section) /�/ (lot number) (grave number)
Name of Sexton or Person in Charge of Premises [/^`°'f b- Stn
2 vv (please print)
1
Signature Title iiZtmrtiOIC
(over)
DOH-1555 (02/2004)