Thompson, Maryellen NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section f 'II Burial - Transit Permit
Name Firsinllaryellen Middle C. ompson Sex Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/05/2012 62 years War or Dates
1- Place of Death Hospital, Institution or
C own or VfiliiiiPc Johnstown Street Address Fc Rhcf
Manner of Death Natural Cause ElAccident El Homicide El Suicide ri Undetermined ri Pending
I Circumstances Investigation
at Medical Certifier Name Title
0 Hassam, Akber Md
AdIronclair Terrace, Johnstown, Ny 12095
» Death Certificate Filed District Number Register Number
Gown or VXiiiigx Johnstown 1754 4
10 0 Burial Date Cemetery or Crematory
02/08/2012 Pine View Crematory
gii 0 Entombment Address
Iii[ 'Cremation Queensbury, N.y>
Date Place Removed
Removal and/or Held
4 El Removal
Address
CA
Hold
0 Date Point of
Di El Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc. 00442
Address. Sherman Ave., Corinth, Ny 12822
Name of Funeral Firm Making Disposition or to Whuensmore Funeral Home Inc.
Remains are Shipped, If Other than Above
Addresix s Sherman Ave., Corinth, Ny 12822
tii
f" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/07/2012 Registrar of Vital Statistics ,�� �
2 (signature)
`: District Number 1754 Place Johnstown
itiiii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k UI Date of Disposition �b V 2O�ZPlace of Disposition -Pi
Place �p
6'►efor,�
(address)
ILI
0
Iz (section) (lot number) (grave number)
Name of Sexton or Pers n in Charge of Premises dc,54,p)e 4."' SPorfft
(please print)
W. Signature -,,. _ - Title - 02En1P C
(over)
DOH-1555 (02/2004)