Johnston Jr, Robert NEW YORK STATE DEPARTMENT OF HEALTH It S 7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Johnston,Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
September 3,2013 69 War or Dates
Place of Death Hospital, Institution or
City,Town or Village Moreau Street Address 4 LaFond Lane
a Manner of Death Q Natural Cause 0 Accident El Homicide Ei Suicide El Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Karissaa Scarbino D.O.
Address
Wilton Family Medicine,135 North Road,Wilton,NY 12831
Death Certificate Filed Moreau District Numbe4562 Register Number
City,Town or Village
O Burial Date Cemetery or Crematory
September 5,2013 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z El Removal and/or Held
and/or Address
F Hold
0 Date Point of
N LiTransportation Shipment
p by Common Destination
Carrier
Ei
Disinterment Date Cemetery Address
Ei Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem s described aabov a ated.
Date Issued 9/.5-43 Registrar of Vital Statistics � ,
/ (signature)
District Number 4562 Place Moreau
I certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
W Date of Disposition `'l-S"(3 Place of Disposition ,vl uu (r;p.c4orhk..
SE (address)
W
IX (section) Jot nu ) (grave number)
pName of Sexton or Person in harge of Pr ises iF (t"^eit
tu
Signature Title C'IZIG11iklat
(over)
DOH-1555(02/2004)