Johnson, Andree NEW YORK STATE DEPARTMENT OF HEALTH
3?1 Vital Records Section Buria - Transit Permit
Name First Middle Last Sex
Andree Celeste Johnson Male
.: Date of Death Age If Veteran of U.S. Armed Forces,
05/16/2016 78 years War or DatesNo
h-- Place of Death Hospital, Institution or
CityXXXIXn)b1fXlinfige Schenectady Street AddressEllis Hospital
tik
W Manner of Death,❑Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
10
Ili Medical Certifier Name Title
Alec B Platt M D
Address
124 Rosa Rd, Schenectady, N Y 12308
Death Certificate Filed District Number Register Number
CityM4nXolEX1a40.fige Schenectady 4601 444
yli['Burial Date Cemetery or Crematory
05/23/2016 Pine View Cemetery
El Entombment Address
!e ['Cremation Town Of Queensbury, N Y
Date Place Removed
Z Removal and/or Held
2 and/or Address
E= Hold
Cl)
Q Date Point of
❑Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Hom4A B Kilmer Funeral Home 01078
Address
136 Main St, So. Glens Falls, N Y 12803
Oii Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
Address
ir
tu
c` Permission is hereby granted to dispose of the human remains descri41 above in7cated.
Date Issued 05/16/2016 Registrar of Vital Statistics
',.Y..- t "(signatur1) -
District Numbe4601 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI P
Date of Disposition 6121 •
��� Place of Disposition • in(U..) lft-,-
a ' (address)
ILI
Cll
CC (section) _(lot number)'. (grave number)
CZ Name of Sexton or Person in Char,,- of Premises " �` *^^r!,
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Signature �'`1.0 Title ��''"i1 W2
(over)
DOH-1555 (02/2004)