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Johnson, Robert C . . / / 5 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit '''` Name First Middle Last Sex Robert E. Johnson Male '' Date of Death Age If Veteran of U.S. Armed Forces, a February 14,2017 68 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death X Natural Cause Accident 1 1 Homicide Suicide Undetermined Pending Circumstances Investigation ' Medical Certifier Name Title Eric Pillemer Address `:', CR Wood Cancer Center,Glens Falls,NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 /J 3 ❑Burial Date Cemetery or Crematory February 16,2017 Pine View Crematory 0 Entombment Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold N O Date Point of N Transportation Shipment p by Common Destination Carrier Disinterment Date I Cemetery Address Reinterment Date Cemetery Address :< Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00037 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom F ' Remains are Shipped, If Other than Above M: Address W. !> Permission is hereby granted to dispose of the huma remain describe above as in icate . i Date Issued C Registrar of Vital Statis • s /7 .01`-( sign"tune) District Number / Place (_ /�7, I certify that the remains of the decedent identified above were disposed of in accor ance with is permit on: Z mi Date of Disposition '2 f/6//7 Place of Disposition �yj�' j/, e (./&p 7c 714,/ W (address)/ U) CL - (section) (lo number) (grave number) pName of Sexton or 1,3‘rsorf in Charge of emises _ ;,.. /i 1,,, / '-Wirt i t L Z / ; l (please print) / W Signature <`.r` :--i • Title C:e/✓1c110( L>ar.ii,Zi 7 / (over) DOH-1555 (02/2004)