Harvey, Gifford Starr NEW YORKSTATE DEPARTMENT OF HEALT
H `1 Burial - Transit Permit
Bureau of Vital.Records
Middle Last Sex
Name First Male
Gifford Starr Harvey
Date of Death Age If Veteran of U.S.Armed Forces,
07/26/2022 85 Years War or Dates 1955-1969
I•, Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Undetermined ❑Pending
E=INatural Cause Accident Homicide Suicide Circumstances Investigation
W
V Title
W Medical Certifier Name PA
CI Kelly Maley
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number392
City,Town or Village 5601
ElBurial Date Cemetery,Crematory or Facility Name
07/27/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
['Donation
Date Place Removed
❑Removal and/or Held
I and/or
CO
Hold Address
Point of
0
O.
['Transportation Date Shipment
Q by Common
Carrier Destination
['Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
LU
CI. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/27/2022 Registrar of Vital Statistics MeganTro(in(ECectronicallySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
W Date of Disposition ,�Z �L1y— o Place of Disposition Ti c V`i w / »�4 (adress)
W
CD
(section) (lot number) (grave number)
g Name of Sexton or Person in Charge of Premises f.m LY ifepN,r�
please prinll
tIJ Signature ,‘,-,2/' Title C.(GA fel r
00H 1555(07/I8)p l of
iNsitiNix :,
.R1 'r) '
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Fine View Cemetsiy Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#