Johnson, Florence ,% 3 Z-1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Florence K. Johnson Female
Date of Death Age If Veteran of U.S. Armed Forces,
04 / 26 / 2016 92 War or Dates N/A
}- Place of Death Hospital, Institution or
ZCity, Town or Village Saratoga Springs Street Address Saratoga Hospital
a Manner of Death Natural Cause ❑Accident El Homicide Suicide 0 Undetermined 0 Pending
ILICircumstances Investigation
la Medical Certifier Name Title
0 Qiong Wang MD
Address
211 Church St Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs
<>ElBurial Date Cemetery or Crematory
04 / 27 / 2016 Pine View Crematory
0Entombmentiiigii Address
iiMDOCremation 21 Quaker Road, Queensbury, NY
Date Place Removed
Z�Removal and/or Held
and/or Address
Hold
w
0 Date Point of
Transportation Shipment
by Common Destination
Carrier
ni
I:Disinterment Date Cemetery Address 111i.
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
Address
402 Maple Ave., Saratoga Springs, NY 12866
iiiig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tt
tit
CL
Permission is h reby ranted to dispose of the human re ins gify‘3ed lib s indica d.
Date Issued 1 `CO Registrar of Vital Statistics {{
(signature)
District Number A sa Place Saratoga Springs , New York
" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
111 Date of Disposition I/Zi IN. Place of Disposition % iL1 04-m0r..
(address)
111
ir (section) r (lot number) (grave number)
0 Name of Sexton or Person in Charge f Premises G�nit • �S
z (pleb se print) .
ig Signature ( Title "' ��-
(over)
DOH-1555 (02/2004)