John, Norma # 37Z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Norma June John Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/03/2018 86 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death au=Natural Cause Ej Accident Homicide 11 Suicide Undetermined ri Pending
Circumstances Investigation_
Medical Certifier Name Title
Matthew Miles MD
Address
,v : 170 Warren St,Glens Falls,New York 12801
• Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 223
Burial Date Cemetery or Crematory
05/08/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Date CemeteryAddress
❑Disinterment
Date Cemetery Address
D Reinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
• 11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
T Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/08/2018 Registrar of Vital Statistics 1426ertt3 Curtis(E(ectromca((ySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition s/S(t4 Place of Disposition -
'e`q (address)
4 (section) of number) (grave number)
A Name of Sexton or Person in Charge of Premises r ,Sim..4
(plekse print)
it-
Signature _ Title /itChtiitt
(over)
DOH-1555 (02/2004)