Johnson III, George NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ft 337
_. Burial - Transit Permit
Name First Middle Last Sex
George William Johnson III Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 30, 2016 73 War or Dates
Place of Death Hospital, Institution or
LAI' City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
.0.
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death ,th Certificate Filed District Numb 6-5 Registgrmber
City, Town or Village Fort Edward peCT
.,• El Burial Date Cemetery or Crematory
May 6, 2016 Pine View Crematory
`❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
4-, and/or Address
Hold
Date Point of
0`❑Transportation Shipment
by Common Destination
a Carrier
❑ Disinterment Date Cemetery Address
-s y❑ Reinterment Date Cemetery Address
�3• v Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
6� Address
136 Main Street, South Glens Falls NY 12803
�• � Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
Q.' Permission is hereby granted to dispose of the huma ai descri d a s indicated.
Date IssuedE52-j(p Registrar of Vital Statistics
at EZZ
District Number1sPlace. WtLV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i , .
Date of Disposition— € Place of Disposition Quaker Road Queensbury,NY 12804
�f I`r (address)
t l b (section) ley mber) (grave number)
Name of Sexton or Person in Charge Premises LL!� (,�^"+ r9`�"
a /PIeasePn
n
Signature Title
(over)
DOH-1555 (02/2004)