Johnny, Howell NtW YORK STATE DEPARTMENT OF HEALTH t 0 I Z7
' Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Johnny Alvin Howell Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 5, 2018 60 War or Dates
• Place of Death Hospital, Institution or
i- City, Town or Village Hudson Falls Street Address 179 Main Street
• Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
es John Stoutenber• MD, M.D. Dr.
Address
WA 102 Park St. Glens Falls, NY 12801
1,1 Death Certificate Filed District Number Register Number
City, Town or Village S '7 d-6
*• 0 Burial Date Cemetery or Crematory
February 7, 2018 Pine View Crematorium
0 Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
4 by Common Destination
Carrier
0 Disinterment
Date Cemetery Address
_ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
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 /-� f/ Registrar of Vital Statistics ( �,
� z
- (signature)
• District Number c 7 ) Place G; //a(i,e, 6 71 ge,f 14 i F?/IS
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/07/2018 Place of Disposition Quaker Road Queensbury,NY 12804
it (address)
it (section) n (lot number) (grave number)
Name of Sexton or Person in Chargeof Pr,ises ( lease print)
Z:. 6 Title /1E "t rv&
Siimmgnature
(over)
DOH-1555 (02/2004)