Johnson, Michael NEW YORK STATE DEPARTMENT OF HEALTH
. � # 5 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael G. Johnson Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 12,2011 59 War or Dates
Place of Death Hospital, Institution or
Z. City, Town or Village Lake George Street Address 2788 State Route 9
pManner of Death X Natural Cause Accident Homicide I 1 Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name Title
O. Aqeel Gillani
Address
CR Wood Cancer Center, 102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Lake George 5651 /3
❑Burial Date Cemetery or Crematory
Entombment October 13,2011 Pine View Crematory
II Address
❑x Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1 Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2. Address
W
a
Permission is hereby granted to dispose of the human rernati s escribed above as indicated.
Date Issued l'/ra/// Registrar of Vital Statistics
(si nature)
District Number 5651 Place Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition to IN Ii► Place of Disposition poviho..1 (, ,.. loriv..._
2 (address)
W
co
0 (section) (lot number) (grave number)
QName of Sexton or Person i Charge of P emises 40)7k r• 1.4et
`LI
Z (please print)
Signature Title (IBC mivodl-
(over)
DOH-1555 (02/2004)