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Greenough, John
NEW YORK STATE DEPARTMENT OF HEALTH 3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Rev. John Francis Greenough Male Date of Death Age If Veteran of U.S. Armed Forces, December 25, 2016 52 War or Dates wPlace of Death "--'1 Hospital, Institution or City, Town or Village ZOO Street Address Samaritan Hospital Manner of Death .i Natural Caus. ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier O'FDplinkP‘s Tip ---4i, icArirlk)-(10141 -1/0( iliql —17-4, Pl/ . Death Certificate Filed--- I District Numb& , A A Register Number City, Town or Village I "t 10 4A (a ) El Burial Date Cemetery or Crematory December 8, 2016 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address E Hold 0 Date Point of ❑Transportation Shipment by Common Destination la Carrier Date Cemetery Address ❑ Disinterment ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is her y g anted to dispose of the human remains described" above as indicated. Date Issued J, f b Registrar of Vital Statistics (Plait (((/yy( L.atatU � J (signature) District Number 4 w2 Place 1:��(, Ha,(.( �...�- I certify that the remains of the decedent identified/above were disposed of in accordance with this permit on: 3d � tu Date of Disposition 12/ /2016 Place of Disposition Quaker Road Queensbury,NY 12804 �lheiii-ell C/ ‘,y 'n„`' (address) in (section) (Igt number) (grave number) Name of Sexto r Pers in Charge of Premises �t."j1�✓1 •( 1 � (please print) Signature Title e rcmafc9 cypic (over) DOH-1555 (02/2004)