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Johnson, Loren c if 8C2 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Loren Clifford Johnson Male z:,: Date of Death Age If Veteran of U.S.Armed Forces, November 11, 2015 89 War or Dates Place of Death Hospital, Institution or at City, Town or Village Glens Falls Street Address Glens Falls Hospital La Manner of Death 0 Natural Cause ElAccident ElHomicide IISuicide ❑ Undetermined ❑ Pending Circumstances Investigation III Medical Certifier Name Title CI Christopher Hoy MD, Address 102 Park Street Suite B2 Glens Falls, NY 12801 Death Certificate Filed District Number Register mber ,, City, Town or Village 5601 X 0 Burial Date Cemetery or Crematory November 13, 2015 Pine View Crematorium A..❑ : Entombment Address I ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address 14, Hold C Date Point of 0 Transportation Shipment :Cif by Common Destination Carrier , Date Cemetery Address ❑ Disinterment ; ❑ Reinterment Date , Cemetery Address G =z« Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 ,A a-- 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 ' Remains are Shipped, If Other than Above 2a Address W Permission is hereby granted to dispose of the human remains descr' ed a ove s in t d. Date Issued 43/2015— Registrar of Vital Statistics �� (signature) District Number 5601 Place -/� A-14/5 a I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: u Date of Disposition 11/13/2015 Place of Disposition Quaker Road Queensbury,NY 12804 (address) I. :It 0' (section) 9 (lot number) (grave number) 0& Name of Sexton or Person in Charge of Premises lgti%t u.- -oaicct (please print) L •Signature ? Title (_6fitpl '.......,.. /1 /4 (over) DOH-1555 (02/2004)