Soderholm Jr, John Fff /
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
47 Name First Middle Last Sex
; John Walter Soderholm Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 16, 2013 58 War or Dates
_'. Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 25 Kirker Drive
Manner of Death Natural Cause El Accident 0 Homicide 0 Suicide 0 Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
John P. Stoutenburg, M.D. Dr.
kid Address
�` ; 102 Park Street Glens Falls, NY 12801
Ai Death Certificate Filed . D District Number Register umber
City, Town or Village U )ail— y/4 ,j'- /
0 Burial Date Cemetery or Crematory
March 19, 2013 Pine View Crematory
❑Entombment Address
®Cremation uaCer Road Queensbury,NY 12804
Date Place Removed
❑ and/or Removal and/or Held Pine View Crematory
Hold Address
Quaker Road Queensbury,NY 12804
Date Point of
- ❑Transportation Shipment
by Common Destination
Carrier
Y 0 Disinterment Date Cemetery Address
h-
Reinterment Date Cemetery Address
Permit Issued to Registration Number
< ,, Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
7 Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r mains descri d above a indicated.
`' Registrar of Vital Statistics -
Date Issued 3/ ,� o`tC�/� 9
� (signature)
rim° District Number S'1 Place 0* 1 4212j( % ) /Le'i
W . I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
§ Date of Disposition Place of Disposition Quaker Road Queensbury,NY 12804 ieyat
e�'ent
(address)
(section) (lot number) (grave number)
Name of Sexton o er on in ge of Premises Ka-zikn d
(please print)
Signature Title ( "� 7
(over)
DOH-1555 (02/2004)