Harris, Sr. Thomas NEW YORK STATE DEPARTMENT OF HEALTH -
Vital Records Section Burial - Transit Permit
Name First Middle Last sr { Sex M
�'lorno..s C, CA-I r i s
Date of Death j Age ! if Veteran of U.S. Armed Forces,
i 2- ZZ-1201% I 7fr, War or Dates —
1-• Place of Deat I Hos ' institution or 1� St reed
WCity,Town o Village ca-Q- G e-orcy--- treet Addres I• 5e..0-
13 Manner of Deathtn Natural Cause El Accident a Homicide El Suicide El Undetermined El Pending
laCircumstances Investigation
ILI Medical Certifier NameTitle Chery Morris
Phy
slc-i cu-)
Address -B ck S..t. `.1i 1-I H W ; C 1 en S Ruts) /\ 12-1
Death Certifica = lied District Number 1 Register Number
City.Town I r Viliag: La.Ke Gem
.. - Cemetery or remat
aBuriai I Z. iZL 12_0I g P► V 1
0 Entombment Address
Cremation 0,ua.Y_.ar' RA., QuSL4. b tA, t - N`4 17-1C314
Date Place Removed
Z Removal i 4 and/or Held
aand/or I Address
tJ3 Hold
0 [Date Point of
6❑Transportation Shipment
ca by Common Destination
Carrier
El
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
- Permit Issued to I Registration Number
Name of Funeral Home Baker Funeral Home I 01130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
II- Remains are Shipped, if Other than Above
2 Address ..
EC
Lu.—
$ Permission is hereby granted to dispose at the human r ains described abo}fe as�i
Date Issued / Z? /Ij Registrar of Vital Statistics J("(2,,iiQ'
(signature)
District Number ilp 2.0 Place
c (Jr
1.-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LaDate of Disposition 4-- -ig Place of Disposition p;n� U�Gv cc'c.�ca(address)
Lt1
U,
in (section) (lot number) (grave number)
CIName of Sexton or Person in Charge of Premises -Teri" 0 S t,r
ease print)
LU Signature t Title Ct''v `ri'0 r
(over)
DOH-1555 (02/2004)