Harvey, Kathy NEW YORK STATE DEPARTMENT OF HEALTH (V
Vital Records Section i Burial - Transit It Permit
T Name First Middle Last Sex
Kathy Elizabeth Harvey Female
-: Date of Death Age If Veteran of U.S. Armed Forces,
April 14, 2012 62 War or Dates
i— Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death a Natural Cause 0 Accident Homicide 0 Suicide Ell Undetermined Pending
Circumstances Investigation
L, Medical Certifier Name Title
0"" Scott Biasetti, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village L�6Q/ / 7g
❑Burial Date Cemetery or Crematory
April 23, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date ` Place Removed
Removal and/or Held
` and/or Address
'~` Hold
Date Point of
c 0 Transportation Shipment
rat by Common Destination
a Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
e Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
2 Address
Ct
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1//f 9 f/ Z Registrar of Vital Statistics IAD c.._&J-r.S4. U0,A,,.{
(signature)
District Number t)b j Place tQ� � 1 S/ 7')
H I certify that the remains of the decedent identified above were disposed -off in
accordance with this permit on:
al Date of Disposition LI POI rt. Place of Disposition Rt,V a-J Crt turiv�
W (address)
CO
i (section) / (lot number) f, (grave number)
0 Name of Sexton or Persil in Charge f Premises
// lt>>k }+t JC�+ �'
lease print)
LUgtit t Signature t Title alATIAI
(over)
DOH-1555 (02/2004)