Johnson, Virginia NEW YORK STATE DEPARTMENT OF HEALTH 11 2 Z
Vital Records Section Burial - Transit Permit
it
Name First Middle Last Sex
Virginia Marie Johnson Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 19, 2013 71 War or Dates
H, Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide n Undetermined 1-1 0 Pending
Circumstances Investigation
WW', Medical Certifier Name Title
Christopher D Hoy, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register ber
City, Town or Village 5601 f�
0 Burial Date Cemetery or Crematory
April 22, 2013 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z 0 Removal and/or Held
0 and/or Address
_. Hold
C Date Point of
a. 0 Transportation Shipment
CO by Common Destination
0 Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
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
O2C Address
W
11" Permission is hereby granted to dispose of the human remains described above as indicat d.
Date Issued Li J Z.oij3 Registrar of Vital Statistics � _
(signature)
District Number 5601 Place 4�*s Fall. /)//c.) f/
—' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i Date of Disposition
position y-Z3-�3 Place of Disposition ��e��P� �,tirq, ,a�.
W (address)
(0
ft (section) (lot numbe (grave number)
0
Name of Sexton or Person in Charg of Premises L^r++r��`,�,�,�. -poi Witt
W', 74 L ! (please print)
Signature Title Cere4 TOC,
(over)
DOH-1555(02/2004)