Haroff, Edward 3
NEW YORK STATE DEPARTMENT OF HEALTH °f . Burial - Transit Permit
Vital Records Section
Name First Middle `.- Last Sex
EDWARD T. HAROFF MALE
Date of Death Age If Veteran of U.S.Armed Forces,
1/10/2014 66 War or Dates 1966-69
I•- Place of Death . Hospital, Institution
Z City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER HOSPITAL
W Manner of Death Natural Undetermined Pending
W' Cause Circumstances Investigation
W Medical Certifier Name Title
p DOUGLAS VANDERBROOK M.D.
Address
43 NEW SCOTLAND AVE ALBANY, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 58
Date Cemetery or Crematory
0 Burial 1/13/2014 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
0 0 and/or Address
I" Hold
Cl)
0 Date Point of
p„ Transportation Shipment
Carrier
O ElB• y Common
5 Destination
❑ Date Cemetery Address
D• isinterment
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home EDWARD L. KELLY FUNERAL HOME 00519
Address
SCHROON LAKE, NY 12870
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ZAddress
W
LI. Permission is hereby granted to dispose of the human remains describe above as indicated. /�-� Q� p�
Date 1/10/2014 Registrar of Vital Statistics e / {/�SH
Issued (si ature) //
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordancee with this permit on:
Z Date of Disposition I/i3I14 Place of Disposition rCr�uOtu.) Cv40.-
W (address)
w
co
cc (section) i(lot number) (grave number)
0
C3 'n'`, jf4✓,}d'
WName of Sexton or Person in Charge of Premise
(please print)
Signature dpL Title cixMNig
(over)
DOH-1555 (02/2004)