Thorsen, Thorbjorn ' r sh tr )1 Cl
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
:Y . Name First Middle Last Sex
`Y ` Male
gw Thorbjom L. Thorsen
Date of Death j Agge If Veteran of U.S. Armed Forces,
7/30/2011 1 89
��* War or Dates no
Place of Death Hospital, Institution or
City. Town Johnsburg Street Address Adk. Tri-Cty Nursing& Rehab
Manner of Death
,2ii Natural Cause 0 Accident El Homicide El Suicide riUndetermined El Pending
Circumstances Investigation
• Medical Cert. ' r Na o n (1 ' Title
t Address
t North Creek,NY
Death Certificate Filed District Number� Register Number
z t Town c i i Johnsburg 3 0
Date Cemetery or Crematory
:. ❑Burial 8/1/2011 Pine View Crematory
Address
Li Cremation Quaker Rd., Queensbury,NY
Date Place Removed
0 Removal and/or Held
. and/or Address
Hold
. . Date Point of
VJ El Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
>: [�Reinterment Date Cemetery Address
Ni: Permit Issued to ' Registration Number
Name of Funeral Home Miller Funeral Home 1 00199
'X Address
jj 6357 State Rte. 30, PO Box 718, Indian Lake, NY 12842
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 remai desc led ab as' "cated." Date Issued 0 / it tt Registrar of Vital Statistics
;:fit
(signature)
si nature
q District Number 66 J\-- (.J U 4
Place �D Y1 do k?n sbU Ir
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition IS tt•i l Place of Disposition ���, .) (Newell)A��
(address)
tR
iS (section) - (lo number) (grave number)
Name of Sexton or Pe on in Charg f Premises 1i r�� kr- ,,.tit-
Z (please print)
Signature Title C1+i ivi
DOH-1555 (10/89) p. 1 of 2 VS-61