VanNostrand, John Michael ZOL
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Michael VanNostrand Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/01/2022 25 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 91 Gage Hill Road,Lake Luzerne Town,New York 12846
0Manner of Death Natural Cause Accident I Homicide DSuicide Undetermined jrtiPending
C. Circumstances Investigation
W) Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Lake Luzeme District Number Register Number
City,Town or Village 5656 6
RBurial Date Cemetery,Crematory or Facility Name
03/04/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O- Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
El
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
H Remains are Shipped,If Other than Above
2 Address
CC
1JJ
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2022 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed)
(signature)
District Number 5656 Place Town Of Lake Luzeme
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition .g^s-Z9ZL Place of Disposition ey'AJe tit Cr`GN(,LLI
r� �y
2 (address)
tU
NCC (section) (lot number) (grave number)
8 Name of Sexton or Person in Charg f Premise KA 5117O 5 h/fl:2
Z (please print)
W Signature h'a Title Q�fTe
DOH-1555(07/18)pi of 2
s._. -
Public Health Law Sec. 4145(2b)
Receipt
,
Human remains of delivered on , 20
i
'.,.Z , ,
GiC
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#