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Royal John N Z NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John N Royal Male Date of Death Age If Veteran of U.S.Armed Forces, 08/19/2021 88 Years War or Dates 1953-55 Place of Death Hospital,Institution or WCity,Town or Village Corinth Town Street Address 415 Center Street,Corinth Town,New York 12822 1p Manner of Death ©Natural Cause ❑Accident ElHomicide 1=1 Suicide D Undetermined Pending 11 Circumstances Investigation W Medical Certifier Name Title CI Robert Love MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Corinth 4553 Burial Date Cemetery,Crematory or Facility Name 08/21/2021 Pineview Crematory ❑Entombment Address ElCremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or , and/or Held F—t Hold Address 0 Date Point of Cl) ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/20/2021 Registrar of Vital Statistics Brenda L Penis(Electronically Signed) (signature) District Number 4553 Place Corinth, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F— / W Date of Disposition -(4�� �� Place of Disposition p�a�e.- v'� C 1,'ni inr(address) W Cl)CC (sects) (lot number) (grave number) SName of Sexton or Person in Cha of Prem. e Tie OnDfi r' W QPC1 Z (please print) W Signature Title ©{—` DOH-1555(07/18)p t of 2 `/, 1 0:15058 Public Health Law Sec. 4145(2b) Receipt .1, ..,..- v ,. , -, - .Human remains of — delivered on i' ° ° - -: , 20 --- -- - , -------'.,,_,.......;,, ..,... Pine View Cemetery Representing the funeral home named toln burial permit i ,_.) 0 • Official Funeral Directors Reg. or License#