Harris, Joann NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joann Mae Harris Female
Date of Death Age If Veteran of U.S. Armed Forces,
1o2/Q7/2012ea h 70 years War or Dates
} Place Hospital, Institution or
Z City, Tow � i Street Address
XX Clcns F^ Glen F I s F.: ital
0 Manner orNath Natural Cause Accident []Homicide Suicide Unde�e?r ed Pending
1. v. Circumstances Investigation
iti Medical Certifier Name Title
0
Address id Cunningham M-D
3 Irongate Plaza, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Tow , i1AxgXX Glens Falls 5601 568
❑Burial 'abate Cemetery or Crematory
❑Entombment Address1 211 1/201 2 Pine View Cemetery
❑C�emation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or -Address
7:4 Hold
t)
Q Date Point of
Transportation Shipment
G by Common Destination
Carrier
[]Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard 11 Baker Funeral Home 01130
Address
111 afeyette Street Oireenshury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
it
to
":' Permission is hereby granted to dispose of the human remains described above as i icated.
Date Issued 12/11/2012_ Registrar of Vital Statistics ,&ja.- �-
(signature) •
District Number 5601 Place r~lens falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Iti Date of Disposition IL-tT-il- Place of Disposition 2)4.4 Cr -s}on.n,
2 (address)
Lu
till
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises I nAr,Q4P- 0"11411'
.2 rr (please print)
`
Signature 4�. Title C "PTOQ-
(over)
DOH-1555 (02/2004)