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Kirkpatrick, Harold . 4oft0 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex Harold Kirkpatrick,MD Male Date of Death Age If Veteran of U.S. Armed Forces, March 27, 2014 74 War or Dates Place of Death Hospital, Institution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital III• Manner of Death l Xl Natural Cause 1-1Accident Homicide ]Suicide Undetermined Pending Circumstances Investigation • Medical Certifier Name Title Joseph C.Minhindu Dr. Address 20 Murray Street,Glens Falls,NY 12801 Death Certificate Filed District Number Registerer City, Town or Village Glens Falls 5601 ❑Burial Date Cemetery or Crematory March 31, 2014 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed ZO n Removal and/or Held and/or Address H Hold W O Date Point of % n Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address 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 s- Remains are Shipped, If Other than Above Address 0. Permission is hereby granted to dispose of the human remains described abbye icated. Date Issued Q3`3i/2004 Registrar of Vital Statistics 44,1--a-- (signature) District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Q1� /� Date of Disposition 7�-/(f Place of Disposition ��c �jam.✓ (address) la CO CL 0 (section) (lot umber (grave number) pName of Sexton . 'er�:on i rge of Premises e� //-. 16w/i>M W (pleas print) Signature ► !��jd1- Title e/71 7( (over) DOH-1555(02/2004)