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Harrison, Dirck Dey NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dirck Dey Harrison Male Date of Death Age If Veteran of U.S.Armed Forces, 11/02/2020 93 Years War or Dates Navy Place of Death Hospital,Institution or Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing ILI ip Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation C Medical Certifier Name Title Leonard Gelman MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 70 ❑Burial Date Cemetery,Crematory or Facility Name 11/04/2020 Pine View Crematory ❑Entombment Address EiCremation Queensbury,New York ❑Donation 3❑Removal Date Place Removed and/or and/or Held Hold Address 0 0• Date Point of N ❑Transportation p by Common Shipment Carrier Destination El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom — Remains are Shipped,If Other than Above 2 Address W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/04/2020 Registrar of Vital Statistics Jenny Linda 9Karte1Te(ECectronicalry Signed) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition f l 15110 Place of Disposition W gddress) W (section) (lot,*mber)_ (grave number) 8 Name of Sexton or Person in Charge Premises l ra' L Z (please pri ) W Signature Title DOH-1555(07/18)p 1 of 2 f Public Health Law Sec. 4145(2b) 014 r ( Z. Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#