O, Malley, Harold Francis E—& A
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Perin
Bureau of Vital Records
Name First Middle Last Sex
Harold Francis O'Malley Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/23/2022 83 Years War or Dates 1963-1965
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death El Natural Cause Accident Homicide Suicide Undetermined Pending
W U Circumstances Investigation
W Medical Certifier Name Title
Jeremy Di Bari MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 497
HBurial Date Cemetery,Crematory or Facility Name
09/28/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0 -
�- Date Point of
U) Transportation
CI Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/28/2022 Registrar of Vital Statistics Megan Nofin(E(ectronica1Ty Signed)
(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:
Z Date of Disposition q 7 ri 1 Z Place of Disposition I '` 41L- /
(addres.�J
W
� (section) it number) —�� (grave number)
SName of Sexton or Person in Charge of Prem. es
Z (please rint)
W Signature Title (t,Y moTO
DOH-1555(07/18)p t of 2
. 016'2 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of " ' ; , ¢ delivered on • , 20
Pine View Cemetery Representing the funeral home-named on burial permit
Official Funeral Directors Reg. or License#