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Harris, Gloria M A ,-), NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gloria M.Harris Female Date of Death Age If Veteran of U.S.Armed Forces, 11/14/2021 93 Years War or Dates F- Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek p• Manner of Death ©Natural Cause Accident Homicide ❑Suicide 0 Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title O Michael Miles MD Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed District Number Register Number City,Town or Village North Creek 5655 44 ❑Burial Date Cemetery,Crematory or Facility Name 11/17/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ElDonation z Removal Date Place Removed and/or and/or Held F Hold Address N 0 O. Date Point of U) El Transportation Shipment p by Common Carrier Destination El Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above t- Address CC f2 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/16/2021 Registrar of Vital Statistics ?Cathleen C.Gorah(Electronically Signed) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IF- I/ W Date of Disposition 0I (t l CI Place of Disposition Z r n11L__ 7ADA..,-� 2 (address) W CC°C L�(section) rS'(lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises Ass [‘,441'tt 2 (please print) Ill . g Si nature r Title (eerwiftrg DOH-1555(07/18)pi of 2 01 Public Health Law Sec. 4145(2b) 1 Receipt Human remains of delivered on , 20 { Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#