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Carlson, Jr. Harry NEW YORK STATE DEPARTMENT OF HEALTH 4( pjVital Records Section Burial - Transi rmit Name First Middle Last Sex Harry Carlson,Jr. Male ▪ Date of Death Age If Veteran of U.S. Armed Forces, • October 1, 2012 86 War or Dates No iPlace of Death Hospital, Institution or City, Town or Village Lake George Street Address 7 Prospect St D21 MI Manner of Death n Natural Cause n Accident Homicide Suicide Undetermined Pending t>i3 Circumstances Investigation Medical Certifier Name Title Donald Merrihew Dr. m:d Address 319 Bay Street,Queensbury,NY 12804 =ay+ Death Certificate Filed District Number Register Number :: City, Town or Village Lake George 670 / ❑Burial Date Cemetery or Crematory October 4, 2012 Pine View Crematorium ❑Entombment Address ©Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed 2 n Removal and/or Held 9 and/or Address H Hold N 0 Date Point of u) Transportation Shipment p by Common Destination Carrier 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 Ik%►; Remains are Shipped, If Other than Above N Address lift :rt;'• Permission is hereby granted to dispose of the human remains descr ed above as indicated. • Date Issued (0/ Lf/ %L Registrar of Vital Statistics )4e2t (signature) District Number 5 j/ Place Lake George I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 16]S I rt Place of Disposition Z0`414 60-ef orw--- 2 (address) W U) Ce (section) - (I t number) (grave number) O Name of Sexton or Person in Charge f Premises /1t, call Zplease print) ua Title 1 n1 W Signature — �} (over) DOH-1555(02/2004)