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Harris, Donald Carlton NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donald Carlton Hams Male Date of Death Age If Veteran of U.S.Armed Forces, 06/09/2021 78 Years War or Dates Army F.. Place of Death Hospital,Institution or WCity,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803 O Manner of Death ❑X Natural Cause ❑Accident ❑Homicide Ei Suicide ❑Undetermined ❑Pending ILI V Circumstances Investigation Medical Certifier Name Title OO Madison Zuis NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 29 ©Burial ! Date Cemetery,Crematory or Facility Name siit 06/14/2021 Seelye Cemetery -..,❑Entombment Address ❑Cremation Queensbury,New York ❑Donation • tEl Removal Date Place Removed and/or and/or Held H Hold Address N 0 fa/) ❑Transportation Date Point of G by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1.. Remains are Shipped,If Other than Above 2 Address Permission is hereby granted to dispose of the human remains described above as Tndtcated. Date Issued 06/11/2021 Registrar of Vital Statistics LeeannMcca6e(Electromi-aKSrgn4 (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 6/1 4/2021 Place of Disposition Ridge Rd Queensbury, NY 1 2 8 0 4 2 (address) W Seeley Cemetery r) i= (section) (lot number) (grave number) gName of Sexton o Person in Charge of Premises Connie Goedert z /1 (please print) W Signature it 11P P` C/ l� Title Superintendent —11 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012858 Receipt Human remains of\'''\.• , -,- .., ', . , , ,- `,;. ,,„,, .., delivered on , i ( J ----- s---, / Pine View CemetOry Representing the funeral-home named on burial permit" Official '----.--! Funeral Directors Reg.or License# ''" -/4 I HARRIS \ NAMEDonald Carlton Harris Age: 78 LF / Lot Owner: Family Lot# Seelye Grave# Case: Concrete Died:6/9/2 0 21 Interred:6. 14.2021 Funeral Home: Regan Denny Stafford Cemetery: Seelye