Hafner, Harry NEW YORK STATE DEPARTMENT OF HEALTH ` 1 4 7yI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Harry Louis Hafner Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 11, 2018 71 War or Dates
• Place of Death Hospital, Institution or
W City, Town or Village Street Address 5675 County Rte 30
CI Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
i Circumstances Investigation
W Medical Certifier Name Title
Denise Richard, NP
I Address
9 Carey Road Queensbury NA INN
Death ertificate Filed District Number Register Number
City,' own .r Village fip-086 619
❑Burial Date Cemetery or Crematory
September 12, 2018 Pine View Crematorium
F❑Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed .
,z ❑ Removal and/or Held
• and/or Address
i_ Hold
CO Date Point of
a ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
_ Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2' Address
W;
�`. Permission is h re by ranted to dispose of the human remai scribed abov: "i i" .ted.
Date Issued 9
J� ��( egistrar of Vital Statistics u e tL i
(signature)
District Number 5'-)5`\ Place I OWV‘ T5-@ IA-Ck'/ \L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WN Date of Disposition 09/12/2018 Place of Disposition Quaker Road Queensbury,NY 12804
LTJ (address)
re (section) (lot number) (grave number)
p• Name of Sexton or Person in Charge of Premises �nr S���tfr
Z (pl ase print)
W Signature i1 . l Title ((EMITM
(over)
DOH-1555 (02/2004)