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Holt, John Jr NEW YORK STATE DEPARTMENT OF HEALTH Vital Records.Section Burial - Transit Permit I.: Name First Middle Last -Sex John W. Holt , Jr Male : . Date of Death Age If Veteran of U.S.Armed Forces, January 10, 1988 20 War or Dates Marine cnrp.a Place of Death Hospital, Institution or it City, Town or Village San Diego, CA Street Address Naval Hosptial Manner of Death ❑Natural Cause ri Accident 0 Homicide []Suicide riUndetermined El Pending r Circumstances Investigation Medical Certifier Name Title '::' M.A. Super, LCDR, MC,USN — f: Address Naval Hospital, San Diego, CA Death Certificate Filed District Number Reap ter Number City,Town or Village San Diego, CA Ei 00 91 : U Burial Date Cemetery or Crematory 0 Entombment Address ❑Cremation %' Date Place Removed XPRemoval and/or Held , and/or Address 11.1 Hold Ct Date Point of V:Q Transportation Shipment gt by Common Destination Carrier []Disinterment Date Cemetery Address Renterment Date Cemetery Address ® July 28, 2021 Pine View Cemetery, Queensbury, NY • : Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 — Address Queensbury, NY f. Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ::: Permission hereby granted to dispose of the hu n r mains descri d above as indicated. -r.; Date Issued .42 c)1 c3(, Registrar of Vital Statistic �- f ?WA) A (signature) }. District Number ©r 5 '7 Place IL I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1t,I Date of Disposition7/28/2021 Place of Disposition 21 Quaker RD Queensbury, NY 12804 y"� 78 JeddDress) N Mohican 1 W (section) number)number) (grave number) gName of Sex or Person in C arge of Premi es Connie Goedertt Z (please print) ILI Signature f/AZi e- p d 2 Title Superintendent (over) DOH-1555(02/2004) Public Health Law Sec. 4145(2b) U 12 867 Receipt Human remains of • , delivered on - , 20 ± • Pine View Cemetery Official Representing the funeral home named on burial permit Funeral Directors Reg.or License# HOLT JR NAME John HOLT Jr. Age: c Lot Owner: John & Lou Ann Holt Lot# Mohican 78 D Grave# 1 Case: Concrete Died: /- e- I988 Interred:7/2 8/2021 Funeral Home: Regan Denny Stafford Cemetery: Pine View