Dark, Harrison NEW YORK STATE DEPARTMENT OF HEALTH . i / l0s-0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harrison A. Dark Male
Date of Death Age If Veteran of U.S. Armed Forces,
Place o eat
12/08/2012 89 years War or Dates
Hospital, Institution or
iTni City, To V. ..- Street Address �S Hospital X ii X Glcns Falls.. Clcns I o ital
i> Manner o eat 111,r, atural Caus Accident ❑Homicide ❑Suicide n e rmined ❑Pending
Iti v Circumstances Investigation
iii Medical Certifier Name Title
0
Address Scan Bain M D
100 Park St. Glens Falls, N Y
Death Certificate Filed District Number Register Number
City, Tov XViiryX Glens Falls 5601 561
[:]Burial Gate- Cemetery or Crematory
❑Entombment Address 2/10/2012 Pine View Crematorium
Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
2 and/or Address
i=` Hold
0 Date Point of
5 0 Transportation Shipment
G by Common Destination
ni Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
ki Permit Issued to Registration Number
pi Name of Funeral Home Maynard n Baker Funeral Home 01130
Address
11 i afayette Street Qiieenshury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
Cr
Ut
?` Permission is hereby granted to dispose of the human remains described above as indicated.
M. Date Issued 12/1 no01 r Registrar of Vital Statistics >A-7
(signature)
District Number Place
5601 Glens Falls
iLI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
l Date of Disposition l2-lZ-it Place of Disposition ftstikv CUM(Mur-
I (address)
LE!
l (section) A (lot numbed (grave number)
aName of Sexton or Person in Charge of Premises /`,r� -� JQN,�A�
Z (please print)
LEA
1IL
Signature 4.5_
Title
(over)
DOH-1555 (02/2004)