Norris, John NEW YORK STATE DEPARTMENT OF HEALTH `L
Vital Records Section y Burial - Transit Permit
Name First Middle Last Sex
Iy . John Peter Norris Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 8, 2012 75 War or Dates
}- Place of Death Hospital, Institution or
City, Town or Village Street Address
:rt Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Matthew Varughese, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number I Register Number
1
City, Town or Village 56 0 / 15 "7
❑Burial Date Cemetery or Crematory
April 12, 2012 Pine View _
❑Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
°' Date Point of
,r❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
1 Address
q 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued L{ /h o a/2 Registrar of Vital Statistics W CLAjp.s.) tj..)
(signature)
District Number 3 6p i Place 6 S o,k\5 � y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/12/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numb (grave number)
Name of Sexton or Person in Cha e of Premises t1t t wrtA
(please print)
,. .,! /
Signature Title C�11-
(over)
DOH-1555 (02/2004)