Ferguson, John Robert 111 ksy
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Robert Ferguson Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/05/2021 80 Years War or Dates 1961-1965
Place of Death Hospital,Institution or
WCity,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
p Manner of Death ❑X Natural Cause 1:1Accident ❑Homicide Suicide Undetermined Pending
(W Circumstances Investigation
81 Medical Certifier Name Title
Leonard Gelman MD
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed District Number Register Number
City,}own or Village Granville 5756 61
Burial Date Cemetery,Crematory or Facility Name
08/09/2021 Pine View Crematory
Enton ment Address
0 Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
H U Hold Address
)
0
0.. Date Point of
U) LI Transportation
8 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
5* Address
CC
W
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/09/2021 Registrar of Vital Statistics Jenny Linda At.ffartefTe(E•lectronicallySigned)
(signature)
District Number 5756 Place Granville, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition Q IIn I 11 Place of Disposition I' o---
ant, v
(address)
IW
(I)
Q (section) (lot number) c (grave number)
0 Name of Sexton or Person in Charge of emises Ir1 L c..) Ott
z (plse print)
W Signature Title �iW
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 015034
Receipt
Human remains of '` delivered on , 20
Pine View Cemetery Representing the funeral home named pn bumial permit
Official Funeral Directors Reg. or License#