Harris, Floyd 1 A73?
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
fj Name First Middle Last Sex
Floyd John Harris Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 28, 2015 75 War or Dates
Place of Death Hospital, Institutiorindian River Rehab & Health Care
City, Town or Village Granville Street Address Center.Inc.
Manner of Death X Natural Cause Accident Homicide n Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain
r , Address
:•::: 100 Park St,Glens Falls,NY 12801
'j•• Death Certificate Filed District Numbe5725 Register Number
-':' City, VillageVillage of Granville /%
:;s; Town or
❑Burial Date Cemetery or Crematory
March 30, 2015 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:;:r Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
{r:r Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
e.r Permission is h reb granted to dispose of the human re Ad ns 'e rib ve as indicated.
'tir Date Issued 4 0 . ill Registrar of Vital Statistics [ •' /
(signature)
District Number 5725 Place Village of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11311 t6' Place of Disposition go/L. Crt..
W (address)
Cl)
tY (section) q(lot number) (grave number)
QName of Sexton or Person in Charge of Premises v/h/. .. Jt��3.4,�7D�,
Z (please print) j
W XH)Signature Title Cix`w►Iqrk
(over)
DOH-1555(02/2004)