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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vitat Records
Name First Middle Last Sex
Male
John Lord
Date of Death Age If Veteran of U.S.Armed Forces,
09/26/2022 91 Years War or Dates 1951-54
1_, Place of Death Hospital,Institution or
`�Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
W Manner of Death ElNaturat Cause ❑Accident Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
v Title
aUJ Medical Certifier Name
Came Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 69
Burial Date Cemetery,Crematory or Facility Name
09/28/2022 Pine View Crematory
9Intonibmeut Address
OCremation Queensbury Town,New York
DDonation
O❑Removal Date Place Removed
and/or and/or Held
!— Hold Address
CO
0
Date Point of
LA❑Transportation Shipment
5 by Common
Carrier Destination
Date Cemetery Address
ODisi nterrnent
Date Cemetery Address
IDReinterment
Permit Issued to Registration Number
Name of Funeral Home M B Khmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1_ Remains are Shipped,If Other than Above
,2 Address
C
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/27/2022 Registrar of Vital Statistics Clime,L Alaimo.(r�Yectrnrrica Sr
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �
Z. I Date of Disposition el 79 17 Z Place of Disposition 'f I mV. — ` -0---
fW (address)
UJ
t!)° (sec-lion) (lot number) (grave number)
IE
0 Name of Sexton or Person in Charge of P raises r, 6-- `'irt
0 (p// ase print)
z r('IS NW
fJ! Signature ��'—: Title
DOH-1555(07/18)p t of z
t� C31
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#