Haughton, John Crossley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
JOHN CROSSLEY HAUGHTON Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 21, 2021 80 War or Dates 04/19/1967-05/03/1971
Place of Death Hospital, Institution or
City, Town or Village Albany Street Address DVAMC 113 Holland Avenue Albany, NY 12208
} Manner of Death❑Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
C) Circumstances Investigation
W Medical Certifier Name Title
O Richa Kaushik MD.
Address
113 Holland Avenue Albany, NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village Albany 0198 026
❑Burial Date emetery or Crematory
ayla) -Ft ncV le.�C C4yv1(UFO
❑ D'Entombment Addr�ss
®Cremation a Llee415 i 0 n ;y
Date Place ReThoved
Z❑Removal and/or Held
H
and/or Address
Hold
0 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 b ihut,-,e,r. t 4 40 Milt 1 hL eDd.l)
Addres 4 e kkr-G h S- L`kQ L A2k r7,et l l 2Z Iko
Name of Funeral Firm Making Disposition or to Whom
M Remains are Shipped, If Other than Above
Address
W
a Permission is hereby granted to dispose of the human re i s de cri was indicated.
Date Issued April 21,2021 Registrar of Vital Statistic s H. Arrington
(signature)
District Number 0198 Place DVAMC, 113 Holland Avenue, Albany,New York 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition y��/-,0,zi Place of Disposition P; ,,3 e ki% -� �, e .,�
2 (address)
W
(section) (lot number) (grave number)
pName of Sexton or Person i Charge remises 1C Mw" �'�
Z, (please print)
ILI Signature
f4/ Title
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b)
Receipt
Human remains of '> delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#