Harrell, Judge Henry V im_
NEW YORK STATE DEPARTMENT OF HEALTH # 03
Bureau of Vital RecordsMillif Burial - Transit Permit
Name First
Middle Last
Judge Henry Harrell V
Date of Death Sex
Age If Veteran of U.S.Armed Forces, Male
08/29/2022 20 Years
Place of Death War or Dates
City,Town or Villa a Hospital,Institution or
g Glens Falls Street Address 67 Cherry Street Apt.2,Glens Falls,New York 12801
• Manner of Death
Natural Cause ❑Accident Ej Homicide ❑Undetermined
Suicide ❑Pending
Medical Certifier Name Circumstances Investigation
Title
Timothy Murphy
Address Coroner
52 Haviland Avenue,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls
City,Town or Village District Number Register Number
5601 450
■Burial Date Cemetery,Crematory or Facility Name
09/02/2022 Pine View Crematory
III Entombment
Address
Cremation Queensbury Town,New York
■Donation
0❑Removal Date Place Removed
F„ and/or and/or Held
N Hold Address
0
O. Date
0['TransportationPoint of
G by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to
Name of Funeral Home Maynard D Baker Funeral Home Registration Number
Address 01130
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F•• Remains are Shipped,If Other than Above
a Address
Q
W
. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/01/2022 Registrar of Vital Statistics 9VfeganWolin(E(ectronica1TySigned)
(signature)
District Number 5801 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition �3-Zp 2� Place of Disposition � 4e 11..-� er�e�o
(address)
w
cn
(section) (lot number) (grave number)
EC
Name of Sexton or Person in Chang f Premises --R.4r'/1ro•..) i,d7
(please print)
Z
W Signature Title v�1tS��2�
0014-1555(070 P 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
t
Human remains of delivered on 1 , 20
Pine View Cemetery 'Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#