Flood Sr, John NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John E. Flood Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/11/1998 76 War or Dates WWII
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 25 Cooper St.
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Joseph C. Mihindu, MD MD
Address
52 Park St. Glens Falls NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward
Date Cemetery or Crematory
❑Burial 10/14/1998 Pine View Crematory
,�C Address
L_'< 1 Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
... ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01057
Address
82 Broadway, Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whom
jg
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem 'ns described above as indicat
Registrar of Vital Statistics
Date Issued O / 9
(signature)
District Number�� Place
I certify that the remains of the decedent identifie above were disposed of in accordance with this permit on:
u
Date of Dispositionb""��Place of Disposition A 7"� � /� > �� /
(address)
Uj
� ( ��� �� �".r�e��' (grave number)
Name of Sext nor Person in Charge Lremises i
(please print)
Signature /,t� Title -
DOH-1555 (10/89) p. 1 of 2 VS-61