Persons, Justin , _ ,..... ht-it 7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
=y; Name First Middle Last Sex
Justin H. Persons Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 1,2016 41 War or Dates
_. : Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 99 Oven Mountain Road
Manner of Death Natural Cause Accident ( 1 Homicide Suicide x Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
u0.: Michael Sikirica MD
:.:: Address
50 Broad St.,Waterford,NY 12188
.a, Death Certificate Filed District Number Register Number
.a
. City, Town or Village T/O Johnsburg 5655 7
❑Burial Date Cemetery or Crematory
March 4,2016 Pine View Crematory
❑Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
Cl)
0 Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
=3 ti Permit Issued to Registration Number
':1ilk Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
:a Name of Funeral Firm Making Disposition or to Whom
r Remains are Shipped, If Other than Above
Address
;., Permission is hereby granted to dispose of the human r mains described above as indicated.
��Date Issued 3-1-1-JDRegistrar of Vital Statistics a,
:.:_,:
______/ \\ _i_ (sig a ure)
District Number 5GSS Place ! e- 4 JE--h lJ� ,
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
I—
Z 7
Date of Disposition 31`l'I Place of Disposition U C�aOr—
W (address)
U)
QW (section) Opt number) (grave number)
Name of Sexton or Person in Charge of Premises atrAceir S
Z (plebse print)
W Signature d411 Title (I2411 II-
(over)
DOH-1555 (02/2004)