Johnson, Garry NEW YORK STATE DEPARTMENT OF HEALTH 140
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
t
Garry Stanley Johnson Male
Date of Death Age If Veteran of U.S. Armed Forces,
, . March 20, 2012 64 War or Dates
F Place of Death Hospital, Institution or
1 1 City, Town or Village Fort Edward Street Address 9 Beverly Street
• Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined r-i❑ Pending
Circumstances Investigation
t . Medical Certifier Name Title
Danushan Sooriabalan, Dr.
Address
126 Ski Bowl Road
Death Certificate Filed DistrictNumer Regist er
City, Town or Village Cf
❑Burial Date Cemetery or Crematory
March 23, 2012 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal
and/or Held
r Address
• Hold
Date Point of
❑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 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 h eby ranted to dispose of the human ains descri boy as indicated.
Registrar of Vital Statisti
Date Issue � ���'-[/71C.O
(signature /
District Numbe / Place i 'c/ ra
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Pin to i-et.) Cr a N•o..t'!sj wl
Date of Disposition 03/23/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
�
(sectio 11 (lot number) (grave number)
Name of Sexton or Per on in Charge of mises I lmdc^ 'brvvi elle
(please print)
Signature Title _aeW1d ati, r
(over)
DOH-1555 (02/2004)