Stubing, Harland if
NEW YORK STATE DEPARTMENT OF HEALTI-t P t`L0
Vital Records Section 1- Burial - Transit Permit
' Name First Middle Last Sex
Harland Henry Stubing Male
r; Date of Death Age If Veteran of U.S. Armed Forces,
' August 8,2013 87 War or Dates _
% Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death uurriNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
William Borgos MD
Address
f 100 Park Street,Glens Falls,NY 12801
f Death Certificate Filed District Number Register Number
{ City,Town or Village Glens Falls 5601 39
❑Burial Date Cemetery or Crematory
August 9,2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road, Queeensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
y ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
7 Permit Issued to Registration Number
f Name of Funeral Home Regan Denny Stafford Funeral Home 01443
<, Address
r 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
,6 Permission is hereby granted to dispose of the huma mains describe above a- indicted.
Date Issued Registrar of Vital Statistics Or_O��
: '. (signature) G`" \
District Number 5 of Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W _Date of Disposition i1��'� Place of Disposition .��r4' V iL-
2 (address)
W
Cl) _ ���,A
re (section) lot nu ber) (grave number)
00 Name of Sexton or Person in Charge of Pre 'ses A, f en
Z (plea print)
W Signature -0-- Title C *1ft~(it.,
(over)
DOH-1555(02/2004)