Evans, Fred D. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Fred D Evans Male
Date of Death Age �If �®rDates
�1974-716
d Forces,
03/08/2020 :::. 64 Years
Place of Death Hospital,Institution or
Z City,Town or Village Johnstown Town Street Address Fulton Center For Rehabilitation And Healthcare
`p Manner of Death �Natural Cause Accident Homicide Suicide Undetermined Pending
U Circumstances Investigation
ILLIQ Medical Certifier Name Title
Gregory O'Keefe MD
Address
847 County Highway 122,Johnstown Town,New York 12078
Death Certificate Filed District Number Register Number
City,Town or Village Johnstown 1754 14
❑Burial Date Cemetery,Crematory or Facility Name
03/11/2020 Pineview Crematory
Entombment Address
RCremation Queensbury Town,New York
Donation
zRemoval Date Place Removed
and/or and/or Held
H N Hold Address
O
N Transportation Date Point p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
F.. Remains are Shipped,If Other than Above
Address
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/10/2020 Registrar of Vital Statistics Nancy M Hart(Electronically Signed)
(signature)
District Number 1754 Place Johnstown, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition �l( IZm Place of Disposition �4 r--�
2 (address)
W
cc N (section) �t number) (grave number)
aName of Sexton or Person in Charge of Premises I L -SY'�
z (please riot)
LU Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013 41 Cl'
Receipt
Human remains of delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#