Johnson, Robert NEW YORK STATE DEPARTMENT OF HEALTH '_".. ft 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert William Johnson Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 19, 2015 80 War or Dates
.0 Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 19 Warren Street
t Manner of Death 0 Natural Cause El Accident 0 Homicide 0 Suicide Undetermined Pending
.4r, Circumstances Investigation
Medical Certifier Name Title
'= John P. Stoutenberg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number R-•ister Number
Ci Town or Villa•e Queensbury n _
0 Burial Date Cemetery or Crematory
February 27, 2015 Pine View Crematory
0 Entombmenttt Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address Hold
Date Point of
ElTransportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
0 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
f Address
t
Permission is hereby granted to dispose of the human re ains described apbyeds indicated.
Date Issued ')i bOt Registrar of Vital Statistics C . f1_t ,
te (signature)
District Number ,sLarrTh Place t ,i
)04
I certify that the remains of the decedent identified above were disposed of in accor nc with this permit on:
Date of Disposition 02/27/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number)_ (grave number)
Name of Sexton or Person i C arge of remises G h"+ 3040
ft (please print
Vr Signature print)
.��. 9 Title
014
(over)
DOH-1555 (02/2004)