Johnson, Norman NEW YORK STATE DEPARTMENT OF HEALTH 4 1 S
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex MOE,
Norman E. Johnson —Romaael-
Date of Death Age If Veteran of. .S. Armed Forces,
06 / 09 / 2017 92 War or Dates 1943-1947
1. Place of Death Hospital, Institution or
WCity, Town or Village Saratoga Springs Street Address Home of The Good Shepherd
£k Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined Pending
i Circumstances Investigation
tu Medical Certifier Name Title
Carl Sgambati MD
Address
3050 NY-50, Saratoga Springs, NY 12866
Death Certificate Filed District Number�� Register uumber
City, Town or Village Saratoga Springs �'��
»>` EiBurial Date Cemetery or Crematory
06 / 09 / 2017 Pine View Crematory
0 Entombment Address
>'' Cremation Queensbury, NY
'` ` Date Place Removed
❑Removal and/or Held
and/or Address
45 Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
igii
. Q Renterment Date Cemetery Address
Permit Issued to Registration Number
iiiip
w:' Name of Funeral Home Compassionate Funeral Care 00364
` '; Address
AO 402 Maple Ave., Saratoga Sp. , NY 12866
mi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
tip
Permission is ere y granted to dispose of the human rem ' cr' d aiaggea indicat .
<: Date Issued LQ O 1r Registrar of Vital Statistics
(signature)
Ui
District Number LIn01 Place Saratoga Springs , New York
F-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
tt✓i Date of Disposition 6(ran Place of Disposition ijt/ Cr•,Np1o�n,`
(address)
ta
ta
CC (section) / Dot number) (' (grave number)
gName of Sexton or Person in Charge of remises • C(r i,,. J yea L a"
(p ase print)/•
Signature Title 10/-
(over)
DOH-1555 (02/2004)