Johnson, Dawna NEW YORK STATE DEPARTMENT OF PFEALTR "
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dawna L. Johnson Female
''' Date of Death Age If Veteran of U.S. Armed Forces,
12/25/2017 63 War or Dates
Place of Death Hospital, Institution or 7 2 3) .cT t 1�1
City, Town or Village-RQttersu C ` Street Address Deceased s Residence
la Manner of Death E Natural Cause 0 Accident El Homicide Ei Suicide El Undetermined Pending .
Circumstances Investigation
W Medical Certifier N e Title
0 -- 0/1 p ,-r p . i, .i i �,•
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ideid7yi, e .2,7!cc / y/at.167/
Death Certificate sled District Number Regi ter umbe
y ,.
City, Town or Village
❑Burial Date or Crematory r---.,
12/26/2017 V i "(r•( ✓�/7 FLU.✓!b1 kT"L-
❑Entombment Address
®Cremation 7 / 2 /
Date i/ Place Removed
z El Removal and/or Held
and/or
Hold Address
Date Point of
0
A. 0 Transportation Shipment
by Common Destination
' Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
fit,:,; Permission is he eby ranted to dispose of the human remains sc above a indic ed.
Date Issued ion dG (1 Registrar ofVi al tatistics J
/ / , v (signet
District Number ,c�' Place A A 1 \Q W �-
'LS-T eki
certify that the remains of the decedent identified above wer: dispo.ed of in accordance with this permit on:
Date of Disposition t 7 1 Place of Disposition P, r o,,nu,le '7
(address)
(section) ` (lot number) (grave number)
0 Name of Sexton or e o in Charge of Premises w/. �n� (
2 -J (please print)
44. Signature Title e,6,-.,2-kr !
(over)
DOH-1555 (02/2004)