Johansen, Warren .. r 4
NEW YORK STATE DEPARTMENT OF HEALTH It /'I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Warren A. Johansen Male
Date of Death Age If Veteran of U.S. Armed Forces,
02 / 15 / 2016 69 War or Dates 1964-1968
1..4, Place of Death Hospital, Institution or
ZCity, Town or Village Troy, New York Street Address 2000 6th Ave., Bldg A, Apt 505
a Manner of Death®Natural Cause Accident Homicide 0 Suicide 7 Undetermined 0 Pending
ILICA
Circumstances Investigation
iti Medical Certifier Name Title
Michael Sikirica MD
gi Address
€<s'a 50 Broad St Ste 1 Waterford, NY 12188
ilgii Death Certificate Filed District Number 'i'' f, to Z Register Number
: City, Town or Village Troy, New York
< ` ®Burial Date 4 , /i / Cemetery or Crematory
Entombment b Pine View Crematory
`_�»::, Address
I. 'ViCremation Queensbury, NY
,:; Date Place Removed
❑Removal and/or Held
,,.J9 and/or Address
C
Hold
Date Point of
Q Transportation Shipment
by Common Destination
iiig Carrier
mi; El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
'f Name of Funeral Home Compassionate Funeral Care, Inc 00364
': a Address
402 Maple Ave., Saratoga Springs, NY 12866
iii>' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
f
'` Permission is he eb granted to dispose of the human remains described above as indicated.
Date Issued a- I Registrar of Vital Statistics -f.Q
(sig ature)
`' District Number K(.0— Place Troy, New York
g I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
141 p Place of Disposition p
Date of Disposition 7�Z�llb P ��AL.. �w+4'}nN.—
2 (address)
ta
CC (section) ji (lot number (grave number)
aName of Sexton or Person ip Charge Premises . £nstyL- tA -
(please print)
Signature Title OC.1 (
(over)
DOH-1555 (02/2004)
/