Johnson, Garry B ` 'C' /d--
NEW YORK STATE DEPARTMENT OF HEALTH- i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Garry B. Johnson Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 20, 2012 86 War or Dates
_ Place of Death Hospital, Institution or
4'' City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of DeathILI Natural Cause El Accident 0 Homicide 0 Suicide 0 Undetermined r7 Pending
.44 Circumstances Investigation
Medical Certifier Name Title
Dominick Carillo, t-1\ D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number _ Register amber
City, Town or Village ,.�j 60 ( 2
❑Burial Date Cemetery or Crematory
December 20, 2012 Pine View
st 0 Entombment Address
� ®Cremation uaer Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held Pine View
and/or Address
Hold Quaker Road Queensbury,NY 12804
"' Date
Point of
11. El Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
IV Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
If Address
Permission is hereby granted to dispose of the human remains described above as,indicated.
, Date Issued 1-21 ' / ( z Registrar of Vital Statistics (. U C.A1vj.^-k, W ."
(signature)
District Number 5 6 0 ( Place G (2,A,--5 t-c.\ 1s )IP 7 Ia 10 I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
:t - Date of Disposition 12/20/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
:' (section) (lot number) (grave number)
'. Name of Sexton or Person in Charge of Premises r ! Y!
(p ase print)
Signature Title CQ g11p Z7i
(over)
DOH-1555 (02/2004)