Pohl, John 1
F NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
{r Name First Middle Last Sex
'r: John Bennett Pohl Male
rj:. Date of Death Age If Veteran of U.S. Armed Forces,
r: , October 28, 2015 71 War or Dates n/a
jr" Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address 24 Sunset Drive
ii Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
• Medical Certifier Name Title
a. Tim Murphy,Coroner
: Address
1 Glens Falls,NY
.r1
.. Death Certificate Filed District NumberRegister Number
City, Town or Village Queensbury, NY 5657 L CDq 1
❑x Burial Date Cemetery or Crematory
❑Entombment October 31, 2015 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
fj; Permit Issued to Registration Number
: , Name of Funeral Home Regan Denny Stafford Funeral Home 01443
fr.; Address
:r 53 Quaker Road, Queensbury,NY 12804 _
ff 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 e ains described abo e( indicated.
: Q. L_v
•••. Date Issued 1-stsx...c-Th Registrar of Vital Statistics
fir+.,?' � 0) 1 �� ` (signature)
r District Numbe ( f Place [ j -- O 1 ' 0 C,,,_ __r�S�
.....
'rf I certify that the remains of the decedent identified above were disposed of in accorda(with this permit on:
I—
W Date of Disposition 1 0T 31 '1 5 Place of Disposition Pine View Cemetery, Oueensbury, NY
W (address)
V) 32A Erie 1
CL (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Connie L. Goedert
Z (please print)
wSignature Title Cemetery Superintendent
(over)
DOH-1555(02/2004)