Johnson, Randy NEW YORK STATE DEPARTMENT OF HEALTH — ` 4 # 21�,
Vital Records SectionBurial - Transit Permit
N. Name First Middle Last Sex
t.„. Randy J. Johnson Male
®.: Date of Death Age If Veteran of U.S. Armed Forces,
°a . March 18,2016 40 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 5 Moffitt Drive
Manner of Death Natural Cause Accident Homicide Suicide Undetermined x Pending
Circumstances Investigation
Medical Certifier Name Title
N.Balasubramaniam Dr.
Address
*• s, 50 Broad St.,Waterford,NY 12188
°:y; Death Certificate Filed District Number Register Amber
• City, Town or Village Johnsburg 5655
❑Burial Date Cemetery or Crematory
❑Entombment March 22,2016 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z —Removal and/or Held
2 and/or Address
H Hold
in
O Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
•aka Permit Issued to Registration Number
'..:1 Name of Funeral Home Alexander-Baker Funeral Home 00037
A Address
1 3809 Main Street,Warrensburg,NY 12885
=:sa Name of Funeral Firm Making Disposition or to Whom
'i Remains are Shipped, If Other than Above
a Address
• Permission is herebygranted to dispose of the human rema ns d ibeJ `bove as indi ted.
p y�
„..• .: Date Issued a1" O)tt egistrar of Vital Statistics(, _ D � ,
:: ignature)
• District NumberS -------..*:i�Q� Placejti skl _Ask)�I
I certify that the remains of the decedent identified above were disposed of in accordan ith this permit on:
W Date of Disposition 31131A, Place of Disposition �,M,tja1.1 G t rt-
2 (address)
W
CL (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises (r,s `�„-ai9-
`Z ( e print)
Signature a !�� Title
(over)
DOH-1555(02/2004)