Johnson, Beverly NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
} Name First Middle Last Sex
Beverly J. Johnson Female
Date of Death Age If Veteran of U.S. Armed Forces,
w . March 2, 2016 83 War or Dates
i... Place of Death Hospital, Institution or
Z; City, Town or Village Granville Street Address Haynes House Of Hope
lit
• Manner of Death 'XI Natural Cause n Accident Homicide Suicide Undetermined n Pending
lit s
Circumstances Investigation
w Medical Certifier Name Title
C: Bryan Smead MD
Address
Bolton Health Center,Bolton Landing,NY 12814
Death Certificate Filed District Number Register Number
City, Town or Village Granville 5756 7
❑Burial Date Cemetery or Crematory
❑Entombment March 4,2016 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or —
Address
H Hold
u) —
O Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
F Remains are Shipped, If Other than Above
21 Address
C
w.
4 Permission is hereby granted to dispose of the human remains described above as indicated.
°: Date Issued 3-3-16 Registrar of Vital Statistics _ )
,--(signature)
District Number 5756 Place T/O Granville,NY i V
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Shill, Place of Disposition Rni 04t.., �ritina{off,,,,;
2 (address)
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to
Ce (section) (lot number) (grave number)
in Name of Sexton or Person in Charge f Premises j�
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z � 1 (ple se print)
Signature G✓� 1 Title 19/i'
(over)
DOH-1555 (02/2004)