Harrison, Joan « ii # 30 L
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
riff: Joan Harrison Female
`,,�.. Date of Death Age If Veteran of U.S. Armed Forces,
1r: April 21, 2015 73 War or Dates
▪ Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide [ Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
rr{. John P. Stoutenburg Dr.
• Address
:t• ▪, Glens Falls Hosp,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
DI City, Town or Village Glens Falls 5601 2-16)
❑Burial Date Cemetery or Crematory
El Entombment April 23, 2015 Pine View Crematorium
Address
t1 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
:;:ta Permit Issued to Registration Number
. Name of Funeral Home Regan Denny Stafford Funeral Home 01443
;▪ Address
::::a 53 Quaker Road, Queensbury,NY 12804
: :r Name of Funeral Firm Making Disposition or to Whom
••r:1Remains are Shipped, If Other than Above
Address
3
il> Permission is hereby granted to dispose of the human remains described above as indicated.
;;;:: Date Issued LI (.zl i5 Registrar of Vital Statistics
(signet r fr?. e)
`:•e. District Number 5601 Place Glens Falls !J V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lu Date of Disposition //ivr Place of Disposition Le (7-,-4r,1 r
Ili (address)
U)
0 (section) 4(lot number) (grave number)
p Name of Sexton or Person in Charge of Premises 14r„+�..numberZ )... (grave
print)
W 4) /...._
Signature Title at.Ci:M+'t et.
(over)
DOH-1555(02/2004)