Franklin, Harriet (4
NEW YORK STATE DEPARTMENT OF HEALTH 1 4t SI -I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harriet Franklin Female
.; Date of Death Age If Veteran of U.S. Armed Forces,
iSeptember 27, 2012 95 War or Dates
..' Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
ciManner of Death X Natural Cause Accident Homicide n Suicide Undetermined Pending
Iii Circumstances Investigation
u Medical Certifier Nam Title
Address ( t
LA. sb tri n is
Death Certificate Filed Di Numb r) Register Number
;:' City, Town or Village Queensbury,NY 5657 / 3
❑Burial Date Cemetery or Crematory
October 1, 2012 Pine View Crematory
❑Entombment Address
Cremation Quaker Road, Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
N
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
:; Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
_:: Name of Funeral Firm Making Disposition or to Whom
}: Remains are Shipped, If Other than Above
5, Address
re
Permission is hereby granted to dispose of the human r mains described ab- - as indicated.
Date Issued -�,p"p.o l Registrar of Vital Statistics et�
:=, (signatu 1
District Number 5657 Place Queensbury,NY as Pi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Place of Disposition
W Date of Disposition to i�,(ll P ��� (1-",-.11/N---
2 (address)
N
0 (section) (lot numbeS (grave number)
gName of Sexton or Person in Charge f Premises Ari
Z PI 1 (please print)
W
Signature _ .�- Title Cketlietlet
(over)
DOH-1555(02/2004)