Johnston, Julia _ b3jNEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Julia Theresa Johnston Female
Date of Death Age If Veteran of U.S. Armed Forces,
• 09/14/2017 86 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
Manner of Death 0 Natural Cause Accident Homicide El Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 118
❑BUrlal
Date Cemetery or Crematory
09/15/2017 Pine View Crematory
El Entombment Address
®Cremation Queenbury, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/15/2017 Registrar of Vital Statistics carol nexBar6er E(ectronicafySignerC
(signature)
District Number 5657 Place Queensbury, New York
yam.
I certify that the remains of the decedent identified above were disposed of in (accordancee with� this permit on:
Date of Disposition ¶,I�'rl Place of Disposition ',ntt1 ' �'' 'vTo4'w
(address)
(section) lot number) (grave number)
Name of Sexton or Person in Charge of Premises /Ant _3'Mitt-
(plea e print)Signature aTitle //�rOft
914—
(over)
DOH-1555 (02/2004)