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Johnson, Lillian NEW YO3,K STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex Lillian C. Johnson Female Date of Death Age If Veteran of U.S. Armed Forces, June 18, 2013 93 War or Dates F. Place of Death Hospital, Institution or Z City, Town or Village Queensbury Street Address Stanton Nursing& Rehab Centre Iii Manner of Death 0 Natural Cause n Accident 0 Homicide n Suicide I I Undetermined 'Pending IliCircumstances Investigation iii Medical Certifier Name Title C Suzanne Blood MD Address 152 Sherman Ave Queensbury,NY 12804 Death Certificate Filed Queensbury District Number a aster Number City, Town or Village 5657 _7 ©Burial Date Cemetery or Crematory ❑Entombment June 20, 2013 Pine View Cemetery Address ❑Cremation Quaker Road, Queensbury, , NY 12804 Date Place Removed Z fl Removal and/or Held and/or Address i" Hold co 0 Date Point of coI I Transportation Shipment a by Common Destination Carrier n Disinterment Date Cemetery Address ri Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Road, Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom I-- Remains are Shipped, If Other than Above 2 Address W Permission is hereb granted to dispose of the human re ains described above as indicated. Date Issued Lai 19. aw Registrar of Vital Statistics ,^ q _ (---% 1u,\ (signature) District Number 5657 Place Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W� Date of Disposition 6/20/1 3 Place of Disposition Pine View Cemetery Ill (address) to Mohican 52 B 2 0 (section) (lot number) (grave number) p Name of S xton or Person in Charge of Premises Connie L. Goedert W � �N . __ ^ (Please print) Signatur ,--- � -- J� Title Superintendent r (over) DOH-1555(02/2004)