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St. John, Susan NEW YORK STATE DEPARTMENT OF HEALTH li it Ii?31 Vital Records Section Burial - Transit Permit Name .irst Middle Last Sex Susan A. St.John Female Date of Death Age If Veteran of U.S. Armed Forces, 10/11/2018 62 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Johnstown Town Street Address Fulton Center For Rehabilitation And Healthcare Manner of Death© Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending Circumstances Investigation Medical C rtifier Name Title „g1 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 58 et ❑Burial Date Cemetery or Crematory 10/17/2018 Pine View Crematory Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold • Date Point of -Q Transportation Sf,Oment by Common Destination Carrier Disinterment Date Cemetery Address 0 LiReinterment Date Cemetery Address sk Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 47. Address 24 Church Street PO Box 500, Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address gi- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/15/2018 Registrar of Vital Statistics Nancy.7fart(EfectronicallySigned) -, (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: Date of Disposition Io In f!($ Place of Disposition Pe4u..- !,�'t,•— (address) (section) (lot numb) (grave number) Name of Sexton or Person in Charge of Premises " 6.- 3/""W Signature /41` (please print)Title 1(1 kz12 (over) DOH-1555 (02/2004)