Bolton, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
, Name First Middle Last Sex
g John E.Bolton Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/14/2018 90 Years War or Dates 1946-1947
Place of Death Hospital, Institution or
49,1
41, City, Town or Village Glens Falls . Street Address Glens Falls Hospital
Manner of Death E Natural Cause 0 Accident 0 Homicide 0 Suicide nUndetermined ri Pending
til
Circumstances Investigation
,' Medical Certifier Name Title
William Cleaver MD
Address
,, 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
. City, Town or Village Glens Falls 5601 22
,.A []Burial Date Cemetery or Crematory
0:' 01/16/2018 Pine View Crematorium
[]Entombment Address
®Cremation Queensbury, New York
Date Place Removed
' ❑Removal and/or Held
and/or
Address
Hold
Date Point of
- Q Transportation Shipment
by Common Destination
r , Carrier
0 Disinterment
Date Cemetery Address
Date Cemetery Address
* Q Renterment
a.,
Permit Issued to Registration Number
xl, Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
'{{ Address
9, 9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
r Remains are Shipped, If Other than Above
Address
711
ffiµ Permission is hereby granted to dispose of the human remains described above as indicated.
} Date Issued ol/1s/2o1s Registrar of Vital Statistics Pg6enA Curtis(ECectronecaCfySi{/ned)
(signature)
'1, District Number 5601 Place Glens Falls, New York
A' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
9,4
Date of Disposition 1/11 I iQ Place of Disposition o f V,i&—, Lei
(address)
MI
a (section) n(lot number)r (grave number)
Name of Sexton or Person in Charge of'py.'.emises �• 4-A
hi Signature 4 Title in P '._
(over)
DOH-1555 (02/2004)