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Johnston, Deborah Kay # 7 27 NEW YORK STATE DEPARTMENT OF HEALTH Burial- Transit Permit Bureau of Vital Records Name First Middle Last Sex Deborah Kay Johnston Female 1 Date of Death Age If Veteran of U.S.Armed Forty." 11/01/2021 69 Years War or Dates 1_ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address 493 Glen Street 5,Glens Falls,New York 12801 IJJ p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide 12 Undetermined ❑Pending W U Circumstances Investigation UJ Medical Certifier Name Title 0 William Parker MD ot Address 9 Carey Road,Queensury Town,New York 12804 Death Certif cafe Fited District Number Register Number City,Town or Village Glens Falls 5601 482 ElBurial Date Cemetery,Crematory or Facility Name 11/03/2021 Pine View Crematorium ElEntombment Address lCremation Queensbury Town,New York ❑Donation Z Removal Date Place Removed and/or and/or Held H Hold Address N 0 d Date Point of Cl) ❑Transportation Shipment Q by Common Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above S Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/03/2021 Registrar of Vital Statistics Rg6ert Andrew Curtis(ECectronica1TySigned) (signature) District Number 5601 Place Glens Falls, 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 Ill N 1 Place of Disposition adN! ul)— /�- d-� 2 W Nir (section) / Jlot number) (grave number) ik 8 Name of Sexton or Person in Charge of P ises tt.i Se %44l* Z (p/At, print) �n W Signature - Titlek ��` DOH-1555(07/18)pi of 2 1 n Public Health Law Sec. 4145(2b) l Receipt 1 Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#