Clausen, Johanna NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Johanna Clausen Female
Date of Death Age If Veteran of U.S. Armed Forces,
04 / 09 / 2020 95 War or Dates N/A
Place of Death Hospital, Institution or
City, Town or Village Wilton Street Address 181 Louden Road
Manner of Death®Natural Cause ❑Accident ❑Homicide Suicide Undetermined Ei Pending
Circumstances Investigation
Uj U Medical Certifier Name Title
Michelle Ryan NP
Address
2554 U.S. 9, Ballston Spa, NY 12020
Death Certificate Filed District Numb Re umber
City, Town or Village Wilton //
€;< ®Burial Date Cemetery or Crematory
04 / 10 / 2020 Pine View Crematory
®Entombment Address
17Cremation Queensbury, NY
Date Place Removed
El Removal and/or Held
and/or Address
Hold
fl Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Sp., NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rema' s described ab9oye as irtdicated.
Date Issued o Registrar of Vital Statistics ck JL
(signature)
District Number 5� Place Wilton , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 0 Zb Place of Disposition pu
(address)
(section) (lot nnVumber) (grave number)
is Name of Sexton or Person ip Charge f Premise ui t� Iik
z (pAhase print) .
Signature Title
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) ` '`� 3 J
Receipt
1
Human remains of .'delivered on , 20
r
Pine View Cemetery Representing the funeral`home named q rial permit
Official Funeral Directors Reg.or License#