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Johnston, Robert NEW YORY STATE DEPARTMENT OF HEALTH 7vJ Vital Records Section Burial - Transit Permit Name First Middle Last Sex Robert Meredith Johnston Male Date of Death Age If Veteran of U.S. Armed Forces, December 16, 2015 94 War or Dates World War II I— Place of Death Hospital, Institution or t ' City, Town or Village Kingsbury Street Address 119 Feeder St. WManner of Death .i Natural Cause El Accident ❑ Homicide ❑ Suicide ❑ Undetermined III Pending W Circumstances Investigation W Medical Certifier Name Title 0 Thomas Kandora, M.D. Dr. Address Broadway Fort Edward, NY 12828 Death Certificate Filed District Number S Register Number City, Town or Village ❑Burial Date Cemetery or Crematory December 21, 2015 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held 0and/or Address El Hold St. Mary's Cemetery N Date Point of ai❑Transportation Shipment CO by Common Destination c Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address Ell Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above 2 Address C W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued /; -,,1 /-/5- Registrar of Vital Statistics C k c a i ut JJ (signature) 5 District Number -2 4 It Place 'c,,h K 6 1 14 S S b lire J J I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- /L^23..IS 2,17 e st,'ea., C mInivivel WDate of Disposition Place of Disposition Quaker Road Queensbury,NY vz804 X (address) fW SGF St Marys iX 6 NbVicliY (lot/ number) (grave number) gyp' Name of Sexton or Person • Charge of Premises ...)1,,..1i a.-h 6-ame..44,C Z (please print) W Signature 1/2- e' Title G/'Gm� (over) DOH-1555 (02/2004)