Johnson, Enoch # 6OZ
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section 4 - e Burial - Transit Permit
Name First Middle Last Sex
Enoch Johnson Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 11, 2012 53 War or Dates Navy
.. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
12$` Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
tit Circumstances Investigation
us; Medical Certifier Name Title
Darci Gaioth Grubbs Dr.
Address
102 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Nu ber
City, Town or Village Glens Falls 5601 07Y
III Burial Date Cemetery or Crematory
November 16, 2012 Pine View Crematorium
❑Entombment Address
❑X Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
Z
and/or Address
F.. Hold
ta
O Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
IDisinterment Date Cemetery Address
IReinterment Date Cemetery Address
Permit Issued to Registration Number
:a:; Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
1'dyyal Name of Funeral Firm Making Disposition or to Whom
t::: Remains are Shipped, If Other than Above
gl gi Address
lit
:. Permission is h reb granted to dispose of the human mains cribed abo as indica ed.
..0,Date Issued I/ /3 (,)Q/ _Registrar of Vital Statistics �C.-�^,--i
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
WDate of Disposition 41 riiiL Place of Disposition Xit,t0uba Co r,v,,..,'
2 (address)
W
CO
Ce (section) /f (lot number) (grave number)
QName of Sexton or Person in Char a of Premises `/A`,) L 3i4nbi'
Z rplease print)
W Signature L1L
Title CIZAE wiIft-17Oil—
(over)
DOH-1555(02/2004)