Harris, Ralph W - - LF /7
NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ralph W.Harris Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/11/2022 77 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
Manner of Death 0 Natural Cause ❑Accident Homicide Suicide Undetermined Pending
111 Circumstances Investigation
a Medical Certifier Name Title
Brandi'Baker NP
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed Town Of Argyle District Number Register Number
Ci ,Town orVillage 5750 15
Burial Date Cemetery,Crematory or Facility Name
04/13r/2022 Pineview Crematorium
Entombment Address
Cremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
51 Hold Address
0
Date Point of
111:1T Shipment
5 by Common
Carrier Destination
'Di Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
i... Remains are Shipped,If Other than Above ,
Address
CC
Uf
Ct. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/13/2022 Registrar of Vital Statistics Shelley Mckernon(Electronically Signed)
(signature)
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed oi in accordance with this permit on:
Z Date of Disposition L/—)3—Zo z Z Place of Disposition P/›)..Bs-.)r"1.,,1 L re,n,a,4 alt
a (address)
ILI
tn, (section) (lot number) (grave number)
Name of Sexton or Perso in Charge of Premises ��- �r�''� G�"n��
(please tint) f�
Signature Title G ���'` Vj '�`r'"/
DOH-1555(07/18) of 2
E. `.
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 -~`
Pine View Cemetery Representing the funeral home named bup;i l permit
Official Funeral Directors Reg.or License# ` °t